Practical 
Lessons 

Nursing 



Aids to Aseptic 
Technique 

B 7 A. D. Whiting MD. 




LIBRARY OF CONGRESS. 



Chap.. .:.".„. Copyright No. 

Sbelf_J?Ofc!?8 



UNITED STATES OF AMERICA. 



AIDS 



TO 



ASEPTIC TECHNIQUE 






BY 



A. D. WHITING, M.D. 

ASSISTANT SURGEON TO THE GERMAN HOSPITAL, PHILADELPHIA 




TWO CWHEtf HCUEIVEO 

PHILADELPHIA *"t \ty^ \q £ 



J. B. LIPPINCOTT COMPANY 

1898 



1 



>A 



11 44 



Copyright, 1897, 

BY 

J. B. Lippincott Company. 



TO 

MR. JOHN D. LANKENAU, 

WHOSE LIBERALITY AND TRUE CHRISTIAN SPIRIT HAVE 

PLACED THE GERMAN HOSPITAL IN ITS 

PRESENT ENVIABLE POSITION 

AS AN INSTITUTION 

FOR THE 

RELIEF OF SUFFERING HUMANITY, 

THIS WORK 

IS MOST RESPECTFULLY 

DEDICATED. 



PREFACE. 



The object of this work is to aid those whose 
duty it is to prepare materials for an operation. 
No attempt has been made to write a treatise on 
the subject of asepsis, but only to furnish aids 
to aseptic technique, and to explain why certain 
procedures are undertaken, and why they give 
the desired results. It was thought that the 
subject might be made clearer to the reader by 
bo doing, and that it might be of more interest 
than would a dry statement of the various 
methods which must be undertaken in order to 
furnish aseptic results. 

The task of those who prepare the materials, 
etc., for an operation is no slight one. At times 
it becomes so burdensome that it would gladly 
be dropped for something more interesting and 
less irksome. If the hints given in this work 
will aid them in their task, making it better 
understood and of more interest, the object of 
the author will be fulfilled. 

5 



CONTENTS. 



CHAPTEE I. 

PAGE 

History of Antisepsis and Asepsis — Principles upon which 
all Technique depends 9 



CHAPTEE II. 

Bacteriology — Description of Special Bacteria — Methods 
for Testing the Sterility of Materials, etc 22 

CHAPTEE III. 

Sources of Infection — The Air — The Field of Operation — 
The Hands of the Operator and his Assistants — The 
Materials used during an Operation 34 

CHAPTEE IV. 

Agents used for procuring Asepsis — Chemicals — Heat 

applied hy Hot Air, Steam, Boiling 47 

7 



8 CONTENTS. 

CHAPTEK V. 

PAGE 

Methods for Procuring Asepsis — Preparation of the 
Patient — The Hands of the Operator and his Assistants 
— Dressings — Gauze — Cotton — Towels — Suits for Op- 
erator and his Assistants — Instruments — Needles — 
Sponges — Catgut — Silk — Silkworm-Gut — Kangaroo 
Tendon — Glass Vessels — Basins — Salt Solutions — Drain- 
age-Tubes, etc 75 

CHAPTER VI. 

The Modern Operating-Eoom — An Aseptic Operation . . 139 



AIDS 



TO 



ASEPTIC TECHNIQUE 



CHAPTER I. 

HISTORY. 

Aseptic and antiseptic procedures have been 
practised since the earliest times. It is almost 
needless to state that there was but little knowl- 
edge of the true principles of the subject in 
those days, and that no scientific reasons were as- 
cribed for the methods undertaken. The whole 
amount of knowledge was limited to the fact that 
wounds did putrefy and that the bodies of the 
dead did undergo changes that destroyed all of 
the semi-solid tissues. In regard to the changes 
in their wounds, the ancients thought that the air, 
itself, was the direct cause of the purulent con- 
ditions. In order to prevent the access of air, 

9 



10 AIDS TO ASEPTIC TECHNIQUE. 

they covered their wounds with clay, and thus, 
to an extent, lessened putrescence. While the 
clay formed a very poor and inefficient dressing 
for a wound, yet it answered fully one of the 
requirements of a good dressing, — namely, the 
power to prevent access of germs from the ex- 
terior. 

In order to preserve the bodies of their dead 
the ancients took more active measures, and used 
strong antiseptics in conjunction with their 
methods to prevent the access of air. After 
having removed the viscera of the abdominal 
and thoracic cavities, they completely filled the 
cavities with herbs of various descriptions, and 
then submerged the bodies in a solution of na- 
tron, where they were allowed to remain for 
varying lengths of time. The bodies were then 
wrapped with different materials, and in this 
condition either buried or placed in sarcophagi. 
That their methods accomplished the purpose 
for which they were intended is well demon- 
strated in the mummies found to-day. 

From ancient times, all who have been inter- 
ested in wounds and in the preservation of both 
animal and vegetable matter have striven to ex- 



HISTORY. 11 

plain why wounds that are exposed to the air 
undergo purulent changes, and why putrefaction 
takes place. The following anecdote is told of 
Sir Joseph Lister, before the germ theory of 
putrefaction had gained much strength. " While 
going round his wards in the Glasgow Royal 
Infirmary one day, Sir Joseph, then plain Mr. 
Lister, came to the bedside of a patient whose 
arm had been severely crushed without the skin 
having received any injury. Turning to the 
assembled students, he said : — ' Gentlemen, I 
have frequently noticed that when severe in- 
juries are received without the skin being 
broken, the cases nearly always recover. On 
the other hand, trouble is always apt to follow, 
even in trivial injuries, when a wound in the 
skin is present. How is this? I cannot help 
thinking that the man who is able to explain this 
problem will be one who will gain undying 
fame.' " 

Lister had little idea at that time that he, him- 
self, would be the one to solve the problem and 
the one to advance a theory the results of which 
have formed one of the greatest blessings man- 
kind has ever received. 



12 AIDS TO ASEPTIC TECHNIQUE. 

But before Lister did this there were other 
scientists at work, and it was mainly through 
their endeavors and from the results of their 
researches that he was able to advance his theory. 
Different conjectures had been advanced from 
time to time in the great endeavor to explain 
the mooted question. It had been well known 
for years that micro-organisms did exist, the first 
having been demonstrated by Leeuwenhoeck, in 
1675. About one hundred years later, in 1773, 
Miiller made an attempt to classify these minute 
organisms. The origin and life of these germs 
were not understood, and but little was known of 
them beyond the fact that they did exist. They 
were supposed to be the result of spontaneous 
generation, which was the accepted theory 
among the scientists of that day. This theory 
claimed that some of the lower forms of both 
animal and vegetable life sprung from lifeless 
matter without the intervention of any previously 
existing parent. 

Spallanzani, in 1776, Franz Schulze, in 1836, 
Schwann, in 1839, Henholz, in 1843, Schroder 
and Von Dusch, in 1854, Pasteur, Hoffmann, and 
Tyndall were all trying to solve the problem of 



HISTORY. 13 

spontaneous generation. The experiments made 
by them were not only highly interesting and in- 
structive, but they also gave results of which we 
take advantage to-day. One of the most impor- 
tant of these was the demonstration by Schroder 
and Von Dusch that a plug of cotton used as a 
stopper would allow a free circulation of air, but at 
the same time would filter all micro-organisms 
from the air. Another was TyndalPs method of 
applying discontinuous heat for the purpose of 
destroying germ life. 

After the theory of spontaneous generation 
had been disproved by the experiments of Pas- 
teur in 1860 and 1865, the scientific battle was 
waged in support of two main ideas, both of 
which were advanced to explain the cause of 
putrefaction. According to one of these, " the 
changes which occur during the process (of 
putrefaction) are held to be from the first the 
result of chemical decomposition in the organic 
substance, whose atoms are in a state of motion 
or activity, which is capable of being communi- 
cated by catalytic action to other organic material 
in contact with it." The second theory, and the 
one universally adopted by the scientists of to- 



14 AIDS TO ASEPTIC TECHNIQUE. 

day, is, to a great extent, the result of the re- 
searches of Pasteur. According to this expla- 
nation, putrefactive changes are due to the 
agency of organic germs. These micro-organisms 
are ever present in the atmosphere, and eagerly 
seek a suitable feeding-ground in the putrescible 
mass, where they may lodge, feed, multiply, and 
thrive, producing chemical decomposition as 
the result of their action. The advocates of the 
first theory took this result to be the cause of 
the putrefaction and, naturally, failed to establish 
their claim. 

After Pasteur had advanced his theory and 
had given some proof of its correctness, there 
were several scientists who at once took up the 
battle and endeavored to substantiate all that he 
had claimed. One of the most active of these 
was Tyndall, who worked coincidently with Pas- 
teur, but independently of him. Both scientists 
endeavored to prove that germs are necessary 
for the production of putrefaction : and Tyndall, 
especially, endeavored to prove that the germs 
are always present in the air. Tyndall's work 
was done not only to sustain the assertions of 
Pasteur, but also to destroy the theory of spon- 



HISTORY. 15 

taneous generation, which was prominent at that 
time. 

Pasteur and Tyndall also claimed that putre- 
faction might be prevented by such means as 
would preclude the entrance of germs to any 
putrescible mass ; and that these germs lived, or 
rather showed signs of life, only under certain 
conditions. For example, it was demonstrated 
that micro-organisms lost all signs of active life 
in high temperatures and also in extreme cold 
(as was shown by the perfect preservation of the 
mammoth found in the Siberian cave thousands 
of years after life had become extinct). Another 
valuable demonstration was that micro-organisms 
could live in a much higher degree of dry heat 
than of moist heat; and that certain solutions 
greatly affected the life of the germs. 

After Lister had thoroughly studied the ideas 
of Pasteur, he endeavored to apply the same to 
the purulent changes that were so evident in 
the wounds of that time. He then advanced a 
theory which has proved the correctness of the 
prophecy he had made years before. And it is 
to him that the medical fraternity is obligated 
for our present knowledge of asepsis and anti- 



16 AIDS TO ASEPTIC TECHNIQUE. 

sepsis. Details of methods may change with 
the ideas of the individual surgeon, great ad- 
vancements may be made in regard to them, but 
the principle which Lister advanced, and which 
is the foundation of all aseptic and antiseptic 
procedures, will always remain intact and can- 
not vary. This principle is "that the decom- 
position of fluids in wounds, their putrefactive 
changes, in short, are directly dependent on their 
impregnation with organic matter floating in 
the air and thence deposited or in other way con- 
veyed to them, fermentative and putrefactive 
changes being thus at once set up in the fluids 
of the wound; that such local actions are 
capable of producing general septic infection of 
the fluids of the body; and further, that these 
organic products may be excluded from the 
wound, either by their destruction in the air by 
chemical agents, such as carbolic acid, or their 
separation from it by filtration, as by layers of 
muslin or cotton-wool." (Erichsen.) 

It is upon this principle that so much has been 
done to revolutionize the practice of modern 
surgery. Every one dealing with wounds should 
thoroughly understand the main points, — namely, 



HISTORY. 17 

that germs are carried into, or deposited in, the 
wounds ; that these germs cause the various 
troubles which the surgeon dreads, — pus, pyae- 
mia, septicaemia, etc. ; and that these troubles 
maybe prevented, in the vast majority of cases, 
by such procedures as will destroy the germs or 
prevent their access to the wounds. 

Lister and his immediate followers used the 
famous carbolic acid spray as a chemical means 
to prevent the access of the dreaded germs. 
This was fairly successful in accomplishing its 
purpose, in that it did prevent the access of 
germs from the air. But it was unsatisfactory 
in many ways. It was troublesome to handle ; 
it was necessary to operate on a wet field and in 
a wet atmosphere ; the acid was irritating to the 
wound and to the face and hands of the operator 
and his assistant. The spray was also discarded, 
because science soon demonstrated that there 
were other avenues of access for the germs be- 
sides through the air, avenues which were not 
attacked by the carbolic spray. Various ways 
have been devised to overcome the danger from 
germ life during operative procedures ; strong 
antiseptic solutions have been used during the 

2 



18 AIDS TO ASEPTIC TECHNIQUE. 

operation ; means have been taken to keep the 
micro-organisms away from the field ; methods 
have been advanced by which the germs might 
be destroyed if present. 

The details of the methods have changed and 
kept abreast with the knowledge of the habits 
and lives of the germs, until, at the present time, 
all preventive measures are taken before the 
operation begins. Through this advancement 
has arisen the aseptic course of procedure, in 
contradistinction to the antiseptic methods of 
Lister. The principal difference in the two 
methods is that means are used in the aseptic to 
preclude the entrance of germs into a wound ; 
in the antiseptic, the means are employed during 
the operation to prevent the access of germs and 
to destroy those that may be present. The for- 
mer is the more prominent in surgery to-day, 
although there are still a few advocates of the 
latter method. And yet it is seldom that we see 
what is generally known as an antiseptic oper- 
ation, if the case with which we have to deal be 
" clean," or aseptic. In all clean cases, — that is, 
in those that are free from septic material at the 
time of operation, — no antiseptic solutions are 



HISTORY. 19 

used. They are omitted because they are un- 
necessary, if the proper care has been taken to 
render aseptic the field of operation, the hands 
of the operator and of his assistants, and the 
instruments and materials brought in contact 
with the wound ; and also because the principal 
antiseptics used, carbolic acid and bichloride of 
mercury, are escharotic in character, and must, 
therefore, cause destruction of tissue- cells if the 
solutions used be at all strong. This escharotic 
action of the chemicals may be aseptic or even 
antiseptic, yet it is bound to cause irritation of 
the wound and interfere with its rapid healing. 
Naturally there are many cases, among them 
accidents, abscesses, infected wounds, etc., where 
it is absolutely necessary to use strong antiseptics, 
not only to thoroughly cleanse the wound, but 
also to destroy all hidden germs. In these cases 
it is essential that antiseptics should be used, and 
often very freely. The rapidity of healing and 
the freedom from further sepsis will be in almost 
direct ratio with the thoroughness with which 
the wound has been rendered clean and free 
from living organisms, the only hindrance to 
rapid healing being the necrosed superficial cells. 



20 AIDS TO ASEPTIC TECHNIQUE. 

Ordinary warm distilled water was for a long 
time advocated as the best solution to be used for 
irrigating and cleansing aseptic wounds. This 
was soon found to be irritating to the tissues, 
especially to the peritoneum and meninges, and 
also very difficult to keep sterile. There seems 
to be a decided tendency in distilled water to 
undergo changes which render it irritating and 
septic, a tendency that is more marked in dis- 
tilled than in ordinary boiled water. To over- 
come the unfavorable action of the distilled 
water salt was added, and a solution was obtained 
which answered every purpose. This solution 
is the " deci-normal salt solution," sterilized. It 
has proved to be non-irritating and very cleans- 
ing, and at the same time easily rendered sterile 
and kept in that condition. In all " clean" cases, 
and especially where they relate to the perito- 
neum or meninges, nothing but the sterilized 
salt solution should be brought in contact with 
the wound. After the latter has been closed, 
the antiseptics may be used to again cleanse the 
field of operation and the surrounding parts, if 
deemed advisable. 

The main points to remember are that infection 



HISTORY. 21 

of a wound is due to the entrance of micro- 
organisms; that these germs maybe prevented 
from entering the wound by certain measures 
undertaken before the time of operation, or de- 
stroyed in the wound, if present ; that no anti- 
septic should be used during an operation on a 
" clean" case ; that a sterilized salt solution is 
the best to use for all irrigating and cleansing 
purposes during an operation on a " clean" case. 



CHAPTER II. 

BACTERIOLOGY. 

It is essential that every one dealing with 
wounds should have some understanding of the 
micro-organisms that are the direct cause of 
wound infection. The operator should have a 
thorough insight into the habitats of germs, 
their modes of living, the difficulty with which 
they are destroyed, the ease with which they 
may be introduced into a wound. To obtain 
this knowledge the operating-room and the bac- 
teriological laboratory should work in conjunc- 
tion with each other, the investigations of the 
latter being applied in the former, and the results 
of these applications thoroughly reinvestigated 
in the laboratory. Without a bacteriological 
research that is thorough and complete no sur- 
geon is able to tell positively why suppuration 
occurred in this wound and not in that one ; 
why this case of infection was so much more in- 
tense than that one; why no suppuration was 
22 



BACTERIOLOGY. 23 

found in this case, when micro-organisms were 
found in one or more of the tests ; why marked 
infection took place in that case, where every test 
showed what was considered a condition of per- 
fect " asepsis." A thorough knowledge of the 
subject, together with a complete investigation, 
will, however, clear up the whole difficulty and 
show almost exactly why perfect results were 
obtained or why infection resulted. 

One very important fact is often overlooked by 
surgeons, and that is that one may be ever so 
careful in regard to antiseptic and aseptic pro- 
cedures and yet have infected wounds. A knowl- 
edge of bacteriology will often clear this up and 
show that infection may take place, and often 
does, through no fault of the operator or his 
assistants. This may be explained by the fact 
that certain bacteria inhabit the skin not only 
of the field of operation but also of the hands 
of the operator and his assistants, and that they 
are so deeply situated that no method yet ad- 
vanced is able to reach them and either inhibit 
their action or entirely destroy them. In these 
cases no one is open to censure for faulty tech- 
nique; but, on the other hand, no one should 



24 AIDS TO ASEPTIC TECHNIQUE. 

ever rely on this excuse when suppuration occurs, 
without a thorough investigation of the other 
sources of infection. Again, the condition of 
the patient should be studied, for many of the 
operative cases are only too prone to afford 
a suitable feeding-ground for infective germs. 
Many cases may be flooded with micro-organisms 
of various descriptions with no resultant infec- 
tion, while others will become infected from the 
slightest amount of germ life possible to com- 
municate to them. This, also, should never be 
taken as an excuse for infected wounds, unless all 
other sources of infection have been thoroughly 
investigated and proved faultless. 

To make sure that the hands and arms of the 
operator and his assistants are sterile, that the 
instruments and materials brought in contact 
with the wound have been thoroughly asepti- 
cized, test cultures must be made before the 
operation takes place. The tests of the hands 
and arms will be of no value for that particular 
operation, as one could not wait twenty-four 
hours for the result to become known before 
operating. They will, however, serve to show 
whether the hands and arms were surgically 



BACTERIOLOGY. 25 

clean or not at the time of the operation, and 
will also demonstrate whether sufficient care has 
been taken to render them sterile. All materials 
should be tested by implantation of small por- 
tions or scrapings on several of the various 
artificial foods supplied by the bacteriological 
laboratory. If no growth result, the surmise 
may well be made that the articles tested are 
sterile and therefore suitable for use. Should 
one or all of these show a growth, the material 
from which the piece was taken should either be 
discarded or again put through the asepticizing 
process. Especially is it essential that every coil 
of catgut should be tested, for there is no material 
used at an operation that may be more faulty. 
This condition is due not to negligence in the 
preparation, but to the fact that the gut is often 
a most favorable hiding-place for micro-organisms 
and a most difficult material from which to re- 
move them. 

The hands of the operator and those of his 
assistants should also be carefully tested, with 
special tests for the under surface of the finger- 
nails. As before stated, the results of these tests 
cannot be utilized for an immediate operation, 



26 AIDS TO ASEPTIC TECHNIQUE. 

but they will show afterward whether the 
methods of asepticizing have been complete 
and thorough. They also act as a check on hasty 
and careless preparation, as a growth in a tube 
will show undeniably that there were germs 
present at the time the test was made, and every 
conscientious person will do his best to obtain a 
report of " no growth" from his test-tubes. 

Care must be exercised in making these tests, 
for without the greatest amount of thoroughness 
they may show growths that have not been 
caused by any micro-organism taken from the 
article tested. The wire loop used for planting 
the material on the medium must be absolutely 
sterile. This can be accomplished by bringing it 
to a white heat in a flame of an alcohol lamp, as 
the heat will destroy all germs that may be pres- 
ent, but will not affect the platinum wire. The 
various media must be sterile; allow them to 
stand twenty-four hours before using them. This 
length of time will be sufficient for the develop- 
ment of any germs that may be present ; if no 
growth result, the tubes may be used. The 
tubes must be free from any septic material, as 
the wire is liable to touch the sides of the tube 



BACTERIOLOGY, 27 

in reaching the culture medium, and thus cause 
infection of the latter with germs that were not 
obtained from the material being tested. The 
tube should be held mouth downward, in order to 
prevent gravitation of germs into it while the 
cotton plug is removed for the purpose of allow- 
ing the entrance of the wire. The cotton plug 
should not be removed until the tube has been 
inverted, nor should it be kept out of the tube 
longer than is absolutely necessary. 

The reader is referred to works on bacteriology 
for the methods of making and sterilizing the 
various culture media that are always used in 
bacteriological investigations. 

The principal micro-organisms which the 
beginner should understand are those that are 
liable to give rise to local suppuration. From a 
point of local suppuration absorption may take 
place, with consequent septicaemia, pyaemia, etc. 
The most important of these organisms are the 
staphylococcus pyogenes aureus, the strepto- 
coccus pyogenes, the staphylococcus epider- 
midis albus, the bacterium coli commune, the 
staphylococcus pyogenes albus, the staphylococ- 
cus pyogenes citreus, the bacillus pyocyaneus, 



28 AIDS TO ASEPTIC TECHNIQUE. 

and the diplococcus pneumoniae. Of these, the 
first five are those with which the surgeon will 
most frequently come in contact, and the follow- 
ing descriptions of them are given simply as aids 
to the beginner in surgical procedures. Those 
who wish a full description of germs and germ 
life must consult the various books published on 
bacteriology. 

The staphylococcus pyogenes aureus is the 
most common micro-organism found in suppura- 
tive processes, and hence of the greatest interest 
to the surgeon. It has been found in the air, in 
the salivary secretions, in nasal mucus, in the 
earth, etc., but the most frequent soils on which 
it lives are the surface of the body and the mu- 
cous membranes. It is a spherical cell, occurring 
singly, in pairs, and in groups. It stains quickly 
in aqueous solutions of the aniline dyes. It is 
not discolored by Gram's method. It grows 
rapidly in the various liquid and solid media. 
It liquefies gelatin, producing a yellow deposit 
in the bottom of the tube after the micrococci 
have come in contact with the air. At first the 
growth is opaque. As the cocci come in con- 
tact with the air at the top of the culture medium 



BACTERIOLOGY. 29 

the yellow color or pigment is formed. This 
pigment is formed only in the presence of oxygen, 
and in this way the aureus can be distinguished 
from some other forms of liquefying cocci. It 
has a remarkable vitality, living for about two 
weeks on a dried cover glass. In media it lives 
for more than a year, and when transplanted 
will give a new growth. Its thermal death-point, 
as determined by Passet, " is between 56° C. and 
58° C, the time of exposure being ten minutes. 
When in a desiccated condition a much higher 
temperature is required, 90° C. to 100° C, for its 
destruction." 

Tests made by mixing certain antiseptic solu- 
tions with gelatin and then impregnating the 
mass with the aureus showed that growth was 
prevented by carbolic acid, 1 to 814, by mercuric 
chloride, 1 to 81,400, and by boracic acid, 1 to 
327. These strengths simply inhibit the growth 
but do not destroy the organism. Exposures to 
bichloride of mercury, 1 to 1000, or carbolic 
acid, 1 to 100, were successful in destroying the 
organism in varying lengths of time. 

The streptococcus pyogenes is one of the 
most frequent bacteria found in pus. It may 



30 AIDS TO ASEPTIC TECHNIQUE. 

occur either alone or in connection with other 
bacteria, especially with the staphylococcus 
aureus. It is found on the healthy mucous sur- 
faces of the mouth and nose. It occurs in chains 
of varying lengths, from four to twenty cells 
being found in the chains. The cells stain 
readily in the aniline dyes and by Gram's method. 
It grows rapidly on almost all of the ordinary 
media used in the laboratory. The streptococ- 
cus does not liquefy gelatin. In stick cultures, 
it will grow along the sides of the stick, with 
but little growth on the surface. The growth 
is semi-opaque and of a slightly grayish color. 
The thermal death-point is between 52° C. and 
54° C. when exposed for ten minutes. Under 
exposure for two hours to the following strengths 
of solutions all germs were destroyed : carbolic 
acid, 1 to 300; mercuric chloride, 1 to 2500; 
peroxide of hydrogen, 1 to 50. 

The staphylococcus epidermidis albus, as 
shown by Welch, of Johns Hopkins University, 
is the most common micro-organism found on 
the surface of the body. It is so deeply situated, 
at times, in the skin that we are unable to reach 
it by any known means of cutaneous disinfection. 



BACTERIOLOGY. 31 

Dr. Welch says, " So far as our observations ex- 
tend, this coccus may be regarded as a nearly, if 
not quite, constant inhabitant of the epidermis." 
It is almost identical with the staphylococcus 
pyogenes albus, but is not so virulent. It differs 
from the aureus in being much less virulent, in 
liquefying gelatin much more slowly, and in 
being almost white in color. It is an almost 
constant bacteria in the skin and in wounds, and 
even in otherwise aseptic wounds. It is said to 
cause suppuration along drainage-tubes, and to 
be the most frequent cause of " stitch abscesses." 
The bacterium coli commune is a constant 
inhabitant of the alimentary tract of man, and 
is nearly always present in the fecal discharges. 
It is usually found as a short rod with rounded 
ends, but sometimes as an oval cell. It stains 
readily in aniline colors, but is discolored by 
Gram's method and by dilute alcohol. It is 
supposed to possess a slight to-and-fro motion. 
It does not form spores. It will grow on almost 
all of the media found in the bacteriological 
laboratory. The growths on gelatin differ in 
form and appearance, sometimes being spherical, 
at other times oval; the color varies from an 



32 AIDS TO ASEPTIC TECHNIQUE. 

amber to a dark brown. Upon potato, the growth 
is brownish yellow in color. It has the power 
of causing local suppuration ; when absorbed 
into the system it causes toxaemia rather than 
septicaemia. It is usually found on an inflamed 
peritoneum, and is supposed to be the cause of 
this inflammation. Peritonitis is often the result 
of the transmission of the coli bacterium from 
the intestine, where it is normally found, to the 
peritoneal cavity, where it finds a much more 
suitable ground for rapid development. 

The staphylococcus pyogenes albus is iden- 
tical with the staphylococcus aureus in size and 
shape. It is less virulent in its action. It lique- 
fies gelatin about as rapidly as does the aureus, 
but the sediment at the bottom of the tube is 
milk-white instead of golden in color. It is 
found in abscesses, either alone or in combina- 
tion with one of the other forms of pyogenic 
organisms. 

Other forms of pathogenic micro-organisms 
are found in septic wounds and in abscesses. 
They are generally associated with one or more 
of the forms above described, and seldom are 
they found alone — that is, as pure cultures. 



BACTERIOLOGY. 33 

Remember that a somewhat thorough knowl- 
edge of bacteriology is necessary for every one 
who has to deal with wounds of any description ; 
that bacteria are found normally in the skin and 
organs of the body ; that it is impossible to reach 
some of these forms by any known means of 
disinfection ; that every possible endeavor should 
be made to be as free from micro-organisms as 
possible. 



CHAPTER III. 

SOURCES OF INFECTION. 

Wounds become infected usually from one or 
more of four sources. These are the air, the field 
of operation, the hands of the operator or of 
his assistants, and the materials used during" the 
operative procedure. These probable sources 
of infection should always be borne in mind 
when arranging for an operation, in order that 
the greatest care may be exercised in freeing 
them from germs. 

The air contains myriads of germs of various 
kinds. Experiments made by Tyndall and others 
demonstrated this fact conclusively. Tyndall's 
experiments were very comprehensive, extending 
over long periods of time and being widely dis- 
tributed geographically. He determined that 
the air in cities and in low regions is much more 
contaminated than it is in the country and in 
high altitudes. He showed that all ordinary air 
contains some germs, which gradually settle, if 
34 



SOURCES OF INFECTION. 35 

the air be undisturbed, until the latter become 
absolutely free from all micro-organisms. His 
experiments with the beam of light are not only 
highly instructive but also very interesting. 

From various researches it has been learned 
that germs are present in the air at almost all 
times and places, but that their abundance varies 
from time to time under certain conditions. 
When the air in a room has been allowed to re- 
main undisturbed for some length of time, all 
germs will gradually settle to the floor. As 
soon as one walks in the room, however, or as 
soon as the air is disturbed by other means, the 
germs are stirred up and distributed through the 
air. They again settle if the air remain quiet. 

The air in the wards of a hospital is especially 
full of germs, many of which are of marked 
pathogenic significance. This is not to be won- 
dered at when one considers the various diseases 
and septic wounds that are generally found in a 
hospital. But they are not so numerous as one 
might expect, for the reason that the moisture 
of the wounds and of the different pathological 
processes prevents the migration of the germs 
through the air. As soon as the micro-organisms 



36 AIDS TO ASEPTIC TECHNIQUE. 

become dry, however, they are wafted hither and 
thither by the currents of air, and gradually 
gravitate to the floor or to the surfaces of the 
patients, the beds, etc. 

Sternberg quotes various experiments that 
have been made to estimate the number of germs 
present in the air. Miguel, for instance, is 
quoted as giving the following results ; the fig- 
ures placed after the localities where the inves- 
tigations were made represent the number of 
germs found in a cubic metre of air : " Rue de 
Rivoli, average for one year, 750; summit of 
Pantheon, 28; Hotel-Dieu, 1880, average for 
four months, male ward, 6300, female ward, 5120 ; 
La Piete Hospital, average for fifteen months, 
11,100." These great numbers may have no 
serious effect in most instances, but if the germs 
be allowed to settle on open wounds, the vast 
majority of the latter would show putrefactive 
changes. In hospital wards it is next to impos- 
sible to remove the germs and thus render the 
air sterile, but in operating-rooms it may be done 
to some extent. This is best accomplished by 
allowing the air to remain quiescent for some 
time prior to the operation, and by not disturbing 



SOURCES OF INFECTION. 37 

it more than is absolutely necessary while the 
room is being used. In the operating-room, 
moreover, the germs may be washed from the 
air to a marked degree by a thorough spraying 
with any solution that will moisten the atmos- 
phere and carry the micro-organisms downward. 
They may then be washed from the floor, while 
in the moist condition, by the ordinary means of 
cleansing. 

It has often been remarked that fewer cases 
of suppurating wounds are found in those patients 
operated upon in private houses than in those 
operated upon in hospitals. This can be readily 
accounted for by the fact that private dwellings 
contain not only fewer germs, but also a de- 
cidedly smaller number of virulent ones. The 
rooms of most dwellings are less disturbed than 
are those of a hospital, and for this reason the 
germs in the former have a better opportunity 
for settling to the floor, or to the curtains and 
other hangings. If the hangings be allowed to 
remain perfectly still, and if the floor be covered 
with wet sheets before there has been much 
moving about in the room, the air of the latter 
will be almost free from germs. For this reason 



38 AIDS TO ASEPTIC TECHNIQUE. 

the room of a private dwelling is more suitable 
for an operation, as far as the presence of germs 
in the air is concerned, than is the hospital. The 
proper care of the air of an operating-room in a 
hospital will, however, lessen this disadvantage 
to such an extent that the hospital will be almost 
as safe, from a bacteriological stand-point, as 
the private dwelling. Many other points are so 
strongly in favor of the hospital, that the private 
dwelling is but little used at present for operating 
purposes. 

Frankland is quoted by Sternberg as having 
" found that fewer germs were present in the air 
in winter than in summer, and that when the 
earth was covered with snow the number was 
greatly reduced, as also during a light fall of 
snow; the air of towns was found to be more 
rich in germs than the air of the country; the 
lower strata of the atmosphere contained more 
than the air of elevated localities." 

Uffelman found that the number of micro- 
organisms in the air was greatly reduced after a 
rain and increased when a dry wind prevailed. 
This is accounted for by the fact that the rain 
will wash the air of most of the germs ; the dry 



SOURCES OF INFECTION. 39 

wind will tend to remove any moisture from them 
and then scatter them far and wide. 

Welz made numerous investigations of the 
air in the regions around Freiburg. He claimed 
to have found forty-five different forms or 
varieties of micro-organisms that were obtained 
directly from the air. 

THE FIELD OF OPERATION AND THE HANDS OF THE 
OPERATOR. 

The surface of the body is constantly the site 
of germs of various descriptions. Many of 
these are markedly pathogenic and liable to set 
up suppuration at any time, if a suitable putres- 
cible surface be presented. These germs find a 
nourishing pabulum, or food, in the exfoliated 
epidermis and in the secretions of the skin. 
The number of them present on the surface of 
the body is influenced by the clothing w T orn, by 
the habits of the individual, and by the natural 
activity of the skin. Cultures can be obtained 
from any portion of the surface of the body, but 
especially from those parts which are the seat 
of hairs and of moisture, as in the axilla. These 
places form a most suitable feeding-ground for 



40 AIDS TO ASEPTIC TECHNIQUE. 

the germs, as they afford more warmth and more 
moisture. Another favorite site is between the 
toes, where the bacterium graveolens is usually 
found. 

Miguel's experiments with waters showed that 
the most fertile supply of micro-organisms was 
obtained from the " wash- waters" from the float- 
ing laundry of the Seine. This water showed a 
greater abundance of germs than even the sewers 
of Paris. Miguel's enumeration gave twenty-six 
million germs per cubic centimetre of water. 
As these germs, or the greater part of them, 
came from the clothing that had been subjected 
to the use of soap and water, one can readily see 
that the surfaces of the bodies from which the 
clothes had been taken must have been well 
supplied with micro-organisms. 

Hohein made numerous investigations to show 
the number of germs that became detached from 
the skin and remained on the clothing worn 
next to the body. He sewed a piece of sterile 
goods to the inside of the underclothing so that 
it came in direct contact with the skin. At the 
ends of varying lengths of time he removed the 
attached piece and divided a quarter of a centi- 



SOURCES OF INFECTION. 41 

metre square into pieces as small as they could 
be made. He then inoculated nutrient gelatin 
with them. Sternberg sums up the results as 
follows : "In an experiment in which sterile 
woven goods were worn next to the skin of the 
upper arm the following results were obtained : 
linen goods at the end of one day, 28, two days, 
4180, colonies ; cotton goods, end of one day, 105, 
end of two days, 1870; woollen goods, end of 
one day, 606, end of two days, 6799. When the 
material had been in contact with the skin for 
four days, the colonies which developed were so 
numerous that they could not be counted." 

The surface of the skin is not alone in its 
suitableness for the growth and development of 
micro-organisms. Maggiora has isolated and 
classified twenty-two different species of bacteria 
from the cultures which he obtained from a 
small piece of the epidermis of the foot. While 
many of these may have been on the surface, 
yet many were deposited in the tissues proper. 
Twenty-two species of non-pathogenic and nine 
of pathogenic micro-organisms have been found 
on the surface of the body. It can be readily 
seen from the above statement that the surface 



42 AIDS TO ASEPTIC TECHNIQUE. 

of the skin is a most favorable site for germs, 
and that they are always to be found there. No 
one will question the statement that great care 
must be taken to remove as many of them as 
possible from the field of operation and from the 
hands and arms of the operator and of his assist- 
ants. Those who realize what a suitable feed- 
ing-ground the skin is, and also the number 
of different forms of germs that may be found 
there, will be persevering in their endeavors to 
render it as free from these germs as possible. 

That frequent washing and scrubbing will not 
suffice to keep the skin sterile is plainly shown 
by the condition of the hands, which are so often 
subjected to the influence of soap and water. 
Although the hands have a smaller quantity of 
loose epidermis attached to them than any other 
portion of the body, yet there are germs always 
present on the surface. The finger-nails, espe- 
cially, form a favorable resting-place for micro- 
organisms, and Fiirbringer has demonstrated 
frequently that the staphylococcus pyogenes 
aureus, associated with other germs, can be found 
almost invariably in this locality. 

The hands of the operator and those of his 



SOURCES OF INFECTION. 43 

assistants are a probable source of infection for 
another reason. They come in almost daily con- 
tact with suppurating wounds, infected wounds, 
abscesses, or other conditions where micro- 
organisms are present and in a virulent state. 
They are liable, therefore, to carry myriads of 
germs with them, and some of these will surely 
find their way Into the fresh wound unless the 
greatest care be exercised. 

MATERIALS USED DURING AN OPERATION. 

It is evident that germs will be present in 
the materials used at an operation unless some 
means have been taken to destroy them. All 
materials have to be handled in the making by 
persons that are far from aseptic. The materials 
themselves are septic in the beginning, and but 
little of the original sepsis has been removed 
from them before they are put on the market 
for sale. 

The gauze, the cotton, the sheets, all contain 
germs of various descriptions, as can be readily 
demonstrated by inoculating a culture medium 
with a piece of the material in question. The 
various forms of sutures are also septic, — that is, 



44 AIDS TO ASEPTIC TECHNIQUE. 

they contain germs, although some contain fewer 
than others. Catgut was supposed to be the con- 
stant seat of bacteria, but Koch has disproved 
this by his experiments, which showed that gut 
will at times be absolutely free from all germ 
life. On the other hand, when germs are pres- 
ent, they may be situated in any portion of the 
strand, deep-seated or superficial. It cannot be 
told definitely, without numerous tests, which 
piece is free from micro-organisms, and there- 
fore every coil must be treated exactly as it 
would be were one positive that germs were 
present. Silk, silkworm-gut, kangaroo tendon, 
etc., are also subject to the presence of germs, 
and care must be exercised to render these ma- 
terials aseptic. Probably the only suture that 
can be considered free from germ life is silver 
wire. It has been shown that the wire in itself 
is antiseptic, and that it will destroy all germs 
that come in direct contact with it. And yet the 
surface of the wire must be sterilized, as germs 
may become attached in such quantities that the 
outer layers will not be subjected to the action 
of the silver. 

Instruments may readily convey germs to the 



SOURCES OF INFECTION. 45 

wound, especially if there be any greasy or oily 
material on them. A perfectly smooth surface 
is less likely to be the seat of micro-organisms 
than is a roughened one, but it must not be 
supposed that the instrument will be free from 
septic matter simply because they are perfectly 
smooth. Every instrument that comes in con- 
tact with the field of operation must be thor- 
oughly sterilized. Germs are certain to collect 
around the joints and hidden portions, and the 
only way to be positive that they will not be 
conveyed to the hands of the operator or to the 
field of operation is by destroying them before 
using the instruments. 

The investigations and reports made in regard 
to the bacteriological condition of different waters 
have been so numerous that almost every one 
knows that most waters always contain micro- 
organisms of different varieties. Waters that 
have been contaminated by sewage are, natu- 
rally, full of germs. Waters taken from deep 
wells and springs are at times practically free 
from all germ life. Hydrant water always con- 
tains micro-organisms of some description. Fil- 
tered water contains decidedly fewer germs than 



46 AIDS TO ASEPTIC TECHNIQUE. 

unfiltered. The difference will depend, to a 
great extent, upon the form and kind of filter 
used. Sternberg quotes the results of Plagge 
and Proskauer's investigations of the water- 
supply of Berlin as follows : " We give the 
figures for a single day, June 30, 1885 : Stralauer 
works, water of the Spree, unfiltered, 4400, 
filtered, 53 ; Tegeler works, waters of the lakes, 
unfiltered, 880, filtered, 44; high reservoir at 
Charlottenberg, 71 ; 75 W, Wilhelmstrasse, 
121." From these reports it can be seen 
that even in filtered waters germs are always 
found. Ice, lake water, well water, all contain 
germs, and must be thoroughly asepticized 
before they are used for operative purposes. 
Much more care must be taken when the water 
used has been contaminated by sewage. 

Waters that may contain but few germs may 
be unsuitable for operative purposes on account 
of the presence of irritating inorganic matter, 
chemicals, etc. These should be removed before 
the water is used. 



CHAPTER IV. 

AGENTS USED FOR PROCURING ASEPSIS. 

It has been shown (page 34) that wounds 
are liable to become infected through the air, 
through the hands of the operator and of his 
assistants, through the field of operation, and 
through the materials used at an operation. To 
avoid infection from these various sources many 
agents have been advocated from time to time. 
Lister at first relied almost entirely upon chemi- 
cal means, especially in endeavoring to render 
the air around the field of operation antiseptic. 
It has since been shown that the air is one of the 
least dangerous of the sources of infection, and 
that the famous carbolic acid spray was really of 
little use. The other sources have taken a much 
more prominent place in aseptic technique, and 
various agents have been suggested by which 
the field of operation and everything coming in 
contact with it might be rendered sterile. 

The numerous chemical methods that have 

47 



48 AIDS TO ASEPTIC TECHNIQUE. 

been tried by surgeons and investigators are 
seldom used at present. This is partly because 
they are not thoroughly efficient, and also because 
simpler and more perfect methods have been 
devised. Investigators, experimenters, and those 
who apply to practice the results of the investi- 
gations of others rely more and more on sterili- 
zation by heat when possible, using chemical 
agents only when necessity compels. Steam 
sterilization under pressure, and boiling, are the 
most practical and effective means by which 
sterile materials can be obtained. Instruments, 
towels, bandages, and dressings may by these 
means be thoroughly asepticized, but there are 
many other important things requiring steriliza- 
tion which cannot be subjected to the heat neces- 
sary to destroy germs. For these the mechani- 
cal or chemical agents must be used. 

The chemical that has held the most prominent 
place among the disinfectants is the bichloride 
of mercury, or corrosive sublimate. It has 
grown in disfavor, however, as a more perfect 
knowledge of its harmful effects has been ob- 
tained. These deleterious effects have been 
especially noted when the solutions were of 



AGENTS USED FOR PROCURING ASEPSIS. 49 

sufficient strength to destroy the germs with 
which they came in contact. It was at first 
thought that a short exposure to a weak solu- 
tion of the sublimate would effectually render 
almost any substance sterile. This has been 
disproved by numerous experimenters, who have 
shown that the favorable results were obtained 
through imperfect methods of testing. That 
bichloride of mercury is a strong antiseptic 
none can deny, but even in this respect it has 
been overrated. 

If all of the injurious effects of the sublimate 
be taken into consideration, it will be seen that 
it should be used as little as possible in open 
wounds. It is liable to cause mercurial poison- 
ing, on account of the fact that it is readily 
absorbed into the system. It is escharotic in 
character, and thus causes a necrotic change in 
the tissues with which it comes in contact. This 
is so even when weak solutions are used, a slight 
film of superficial necrosis being evident under 
the magnifying-glass. It is a decided irritant to 
a wound. It causes coagulation of the albumen 
of the fluids of the body. An aesthetic fault to 

be found with it lies in the fact that it will dis- 

4 



50 AIDS TO ASEPTIC TECHNIQUE. 

color the finger-nails a dark brown or black 
color. This discoloration cannot be removed, 
and the result is that the operator who uses a 
fairly strong solution of the sublimate will have 
unsightly finger-nails. 

Carbolic acid is another very strong antiseptic 
which has been widely used. It is not so power- 
ful as the bichloride of mercury. It is a decided 
poison, and should be used carefully in all open 
wounds. It is soluble in w^ater up to about 
five per cent., but in making a solution of this 
strength an equal amount of glycerin should be 
added for the purposes of aiding the water in 
dissolving the acid. One marked disadvantage 
in carbolic acid is that it causes a disagreeable 
burn of the tissues when used in strong solutions. 
A weak solution of the acid is escharotic in 
action, causing a minute superficial necrosis. It 
is readily taken up by the fluids of the body, 
with resultant poisoning. Locally, it causes irri- 
tation and prevents rapid healing. It is a local 
anaesthetic when used in strong solution. 

Permanganate of potash is one of the chemi- 
cal agents most widely used in surgery to-day. 
It is very slightly germicidal in solutions ranging 



AGENTS USED FOR PROCURING ASEPSIS. 5J 

from one-tenth to ten per cent, (saturation). It 
is used principally for the purpose of cleansing 
the field of operation and the hands and arms 
of the operator and of his assistants. It must 
be followed by either sulphurous acid or oxalic 
acid. It is claimed that the permanganate in 
itself possesses very slight germicidal power, 
but that its antiseptic effect is greatly enhanced 
by the use of either of the acids. The perman- 
ganate solution will stain the tissues a dark 
brown. This action is a very useful one, in that 
it will show plainly that every portion of the 
surface intended to be rendered sterile has been 
exposed to the action of the solution. As the 
stain can be removed only by the use of sul- 
phurous acid or oxalic acid, a thorough washing 
of the discolored surfaces with one of the acids 
is absolutely necessary. 

Formaldehyde is a chemical that has absorbed 
the attention of the medical and sanitary worlds 
for the past two years. If all that has been 
claimed for it should prove to be true, formal- 
dehyde will play a most important role in aseptic 
surgical procedures, even supplanting all other 
agents used for sterilization and disinfection. 



52 AIDS TO ASEPTIC TECHNIQUE. 

Formaldehyde is a gaseous compound having 
the formula CH 2 0. It was first discovered by 
Yon Hoffmann in 1867, who obtained the gas by 
passing the vapor of wood alcohol mixed with 
air over finely divided platinum heated to red- 
ness. Its strong antiseptic powers were discov- 
ered by Loew in 1888. Berlioz, Trillat, and 
others made special investigations with respect 
to its germicidal powers in 1890. Since that 
time efforts have been made to produce the gas 
at a small cost and in such a manner that it may 
be used readily as generated. This has been 
accomplished, and various forms of portable 
generators have been put on the market. The 
principle of generation is practically the same in 
all of these various apparatus c It depends upon 
the fact that when the vapor of methyl alcohol 
is passed over a coil of glowing platinum wire 
or gauze, or over platinized asbestos, partial 
combustion of the vapor occurs, resulting in the 
formation of a highly pungent gas, formalde- 
hyde. (Fig. 1.) 

Formaldehyde is a pungent, very penetrating, 
neutral gas, with a specific gravity about the 
same as that of ordinary air. It is free from 



Fig. 1. 




54 AIDS TO ASEPTIC TECHNIQUE. 

toxic properties and also from escharotic action. 
It is markedly irritating to an open wound, and 
to the mucous membranes of the mouth and 
nose and to the conjunctivae at first exposure. 
These delicate membranes soon become accus- 
tomed to the vapor, and can then tolerate it 
with practically no discomfort. In concentrated 
aqueous solution formaldehyde acts very simi- 
larly to carbolic acid, in that it renders the skin 
white and free from sensation. When applied 
to a wound it produces a stinging sensation; 
upon the unbroken skin it causes no pain. 

The germicidal powers of formaldehyde are 
said to be dependent upon the fact that the gas 
unites with all albuminoid, sulphuretted, and 
nitrogenous substances. This action is said to 
cause a chemical and structural change in these 
substances, and hence causes absolute destruc- 
tion not only of the germs themselves but also 
of the food upon which the micro-organisms 
live. The chemical compounds resulting from 
these combinations are not only free from all 
germ life but are also antiseptic. 

The true value of formaldehyde lies in the 
fact that it is very penetrating and in the various 



AGENTS USED FOR PROCURING ASEPSIS. 55 

uses to which it may be put. Its penetrating 
power has been investigated by Roux, Trillat, 
Pottevin, and others. " Roux and Trillat have 
discovered an ingenious method of testing the 
penetrating powers of formaldehyde. Its action 
on gelatin is to render it insoluble; to make use 
of this property as a test little cubes of glass 
are coated with liquefied gelatin. When the 
gelatin has set, these are placed in various posi- 
tions in the room which is being sterilized, and 
after the process is completed, examined by im- 
mersion in water. It is found that on those 
cubes which have been exposed to the action of 
formaldehyde the gelatin coating is insoluble." 
Their experiments showed that the gas pene- 
trated every portion of the exposed room, found 
its way through many thicknesses of blankets, 
and even penetrated mattresses. The temper- 
ature necessary for the best results is 35° C. 

The only germs that have been found to with- 
stand exposure to formaldehyde are the bacillus 
subtilis and the bacillus mesentericus, both of 
which are practically unimportant. Solutions 
of formaldehyde of different strengths have 
been thoroughly tested with varying results. 



56 AIDS TO ASEPTIC TECHNIQUE. 

Wortman has made investigations with solutions 
ranging from 1 to 2,500,000 to 1 to 2.5. He says 
that " it is evident without further proof that in 
formaldehyde we possess a substance that has 
a very deleterious effect upon vegetable life, and 
is therefore an antiseptic of high rank, which, 
almost equalling corrosive sublimate in its action, 
ought to supersede not only that but also car- 
bolic acid." 

F. C. J. Bird has prepared the following table, 
which shows some of the purposes for which 
formaldehyde may be used in solution, and also 
the strengths of the solutions : 

» A solution of formaldehyde Effects produced- 

containing 

1 part in 125,000 parts . . . kills anthrax bacilli. 

1 part in 50,000 parts . . 4 . prevents the development of ty- 
phus bacilli. 

1 part in 32,000 parts .... preserves milk for several days. 

1 part in 25,000 parts .... forms a useful injection in leu- 

corrhcea, etc. 

1 part in 20,000 parts .... preserves wines, weak alcoholic 

liquids, and beer, also milk for 
several weeks. 

1 part in 4000 parts .... recommended for moistening 

paper used to cover jam, etc. 

1 part in 3200 parts .... for rinsing dairy vessels, etc. 

1 part in 2500 parts .... destroys the most resistant micro- 
organisms in one hour. 



AGENTS USED FOR PROCURING ASEPSIS. 57 

" A solutioiTof formaldehyde Effects produced< 

containing 

1 part in 2000 parts .... for rinsing casks and vessels in- 
tended for liquids liable to fer- 
mentation. 

1 part in 500 parts for the irrigation of catheters, 

etc., and as a mouth-wash. 

1 part in 250 to 200 parts . . a general disinfectant solution for 

washing hands, instruments, 
etc., in surgery, spraying in 
sick-rooms, and as a deodorant. 

1 part in 160 to 100 parts . . for hardening microscopic tissues, 

which should be immersed for 
a considerable time to give the 
best results. 

1 part in 100 parts in lupus, psoriasis, and skin dis- 
eases. 

1 part in 50 to 25 parts . . . sterilizes surgical catgut, silk, 

etc., by steeping." 



From this table it can be seen that formal- 
dehyde promises to have a wide field of useful- 
ness. These solutions depend for their value on 
the evaporation of formaldehyde. Since this is 
the case, the gas itself should be used as gener- 
ated whenever possible. Care should be taken 
to keep the gas confined, as it readily mixes with 
the air and passes from the room or from any 
container, unless all exits be tightly closed. 

In the sterilization of surgical instruments and 



58 AIDS TO ASEPTIC TECHNIQUE. 

materials the various articles are exposed to the 
formaldehyde gas. They are placed in a vessel 
or appliance made for the purpose, and into 
which the vapor is introduced directly from the 
generator. The length of exposure necessary 
depends upon the concentration of the gas, a 
highly condensed vapor requiring less time than 
one less concentrated, and vice versa. 

When sterilizing a room with formaldehyde 
the doors and windows must be tightly closed, 
and the generator then put into action. As the 
gas develops it will penetrate every portion of 
the room, attacking the hangings and entering 
even the cracks and crevices. After an exposure 
of an hour or two, a window may be opened to 
allow the gas to escape. Any excess of the 
vapor that may remain can be neutralized by 
evaporating ammonia water in the room. 

Formalin is a forty per cent, solution of for- 
maldehyde. It is very volatile, and depends 
upon the gas liberated for its germicidal proper- 
ties. It is claimed that it is an ideal preparation 
for sterilizing towels, blankets, brushes, etc., as 
it is germicidal and but little care is needed 
in using it. Formalin is said to possess the 



AGENTS USED FOR PROCURING ASEPSIS. 59 

power of preventing the development of putre- 
factive germs in a 1 to 10,000 solution. 

Glutol is a new preparation that is said to be 
a perfect dressing for fresh wounds. It is a 
chemical compound, formed by evaporating an 
aqueous solution of gelatin over the vapor of 
formalin. It is a non-irritating and non-poi- 
sonous powder. It depends upon the vapors 
given off for any germicidal action it may pos- 
sess. It is claimed to form a scab over the 
wound and thus prevent infection from without. 
Schleich, the discoverer of the compound, says 
that it will prevent infection to a marked degree, 
and that it will destroy germs by giving off some 
of the formalin vapor. 

Iodoform is a chemical compound that has 
been very widely used as a powder for dusting 
wounds. It is not a true antiseptic, as germs 
are able to live and thrive in its presence. It de- 
pends upon the liberation of free iodine for any 
germicidal action it may possess. It is poisonous, 
causing a vesicular inflammation of the skin. 
It possesses a disagreeble odor, which makes it 
very offensive to some patients. 

Many other compounds have been put on the 



60 AIDS TO ASEPTIC TECHNIQUE. 

market which resemble iodoform, in that they 
depend for germicidal action on the liberation of 
free iodine. 

Citrate of silver and lactate of silver are two 
new antiseptics that have been discovered by 
Crede. They are said to possess decided ger- 
micidal powers, the citrate in a 1 to 3800 solu- 
tion being able to kill schizomycetes in fifteen 
minutes. This salt is best used in a 1 to 4000 to 
a 1 to 8000 aqueous solution. It will be noticed 
that the chlorides in ordinary water will cause a 
cloudiness of the solution ; if distilled water be 
used, this cloudiness will not be present. The 
citrate of silver is less irritating than the lactate, 
and for this reason is often preferable. 

Silver wire and silver foil have lately been 
used to a great extent in surgery. The foil is 
applied over the wound after it has been closed 
by the use of silver wire sutures. It is claimed 
that the silver prevents infection from the ex- 
terior, and also destroys any germs that may 
come in contact with it. It is well to remember 
that the silver foil, when placed over a wound, 
will interfere with the absorption of discharges 
that may come from the latter. (Page 97.) 



AGENTS USED FOR PROCURING ASEPSIS. 61 

Turpentine is used quite extensively by some 
surgeons in cleansing the skin of the hands and 
of the field of operation. It has but little, if 
any, antiseptic action. Its main use is to remove 
all fatty and oily matter that may be present. It 
must be followed by soap and hot water in order 
that it may be removed from the skin. It is 
irritating, and decidedly so on some skins. 
"When turpentine enters a break in the skin it 
causes a stinging sensation and such decided 
irritation that prompt healing is prevented. 

Ether is used quite extensively in aseptic and 
antiseptic procedures. Its chief value lies in its 
power to dissolve various chemicals and fats, 
such as iodine, iodoform, resins, fats, bromides, 
bromoform, volatile oils, most alkaloids, and 
some organic acids. It must be carefully used 
near an open flame, as it evaporates readily and 
explodes when mixed with a certain quantity of 
air. Its main use in surgery is to dissolve fatty 
matter from the skin and materials needed ; its 
germicidal power is very slight. 

Although alcohol has been used since ancient 
times in the treatment of wounds, it is but 
recently that it has taken a prominent place in 



62 AIDS TO ASEPTIC TECHNIQUE. 

antiseptic and aseptic technique. Its value in 
dressings depends upon the power it possesses 
to arrest hemorrhage, to coagulate the albumen 
of exuded serum, to prevent putrefaction of dis- 
charges, and to promote cicatrization. Blair, 
Perrin, Plessing, Holgate, and others have used 
it as dressings and as a special form of treatment 
for surgical affections. Alcohol has the power 
of dissolving many substances, but is not so 
efficient in this action as ether. 

Its decided usefulness in aseptic technique has 
been advocated by Fiirbinger and Freyham, 
who have made numerous experiments with the 
various methods used for disinfecting the skin. 
They claim that alcohol is the best agent obtain- 
able, because it acts as a bactericide, loosens 
superficial epidermis and dirt, and also dissolves 
fats that may be present. (Page 87.) 

Oreolin is used quite extensively as a disinfect- 
ant. It forms a turbid, milky mixture with 
water. It is germicidal in action, and is a 
marked deodorant; it has, therefore, found a 
prominent place in the treatment of suppurating 
wounds having a foul discharge. It relieves 
pain, checks hemorrhage, and limits suppura- 



AGENTS USED FOR PROCURING ASEPSIS. 63 

tion. It is somewhat poisonous when used 
freely, and may cause an eczematous eruption 
with slight rise of temperature. It makes the 
skin rough and slightly discolors it. Creolin 
should be used in a one-half to a one per cent, 
aqueous solution. 

Lysol contains about fifty per cent, of creosol, 
upon which it depends for its germicidal power. 
It mixes with water to form a liquid which has a 
decided saponaceous actiom Cramer and Weh- 
mer, while experimenting with lysol, determined 
that it was five times as strong as carbolic acid 
and one-eighth time as poisonous. It is espe- 
cially adapted for purposes of cleansing on ac- 
count of its soapy character. It is non-irritating 
and practically non-poisonous. Instruments, cat- 
gut, etc., when placed in lysol become very slip- 
pery, and for this reason it is seldom used for 
disinfecting instruments or materials. It should 
be used in a one per cent, aqueous solution. 

These and many other chemicals have been 
advocated from time to time for use in the prep- 
aration of materials for operations. With the 
advent of aseptic surgery chemicals have been 
dispensed with as far as possible in the prep- 



64 AIDS TO ASEPTIC TECHNIQUE. 

aration for an operation, and almost entirely 
during an operation. Heat has superseded 
chemicals, and it is to-day the most widely used 
agent for destroying pathogenic germs. The 
heat is applied by means of boiling water, hot 
air, or steam. Boiling water is used whenever 
practicable, as it furnishes the simplest and 
surest means for procuring the desired result, — 
freedom from septic material. All instruments, 
silkworm-gut, etc., are sterilized by boiling. 
Dry heat has been advocated for the sterilization 
of some materials, such as catgut, but it is not 
satisfactory, because it is hard to apply and be- 
cause a dry heat that is intense enough to destroy 
germ life will often impair the material subjected 
to its action. Steam, however, has no such ob- 
jection, and with it a moist temperature may be 
obtained that will effectually destroy all germs 
without injuring the materials. 

Many mechanical devices have been invented, 
under the name of sterilizers, for the purpose 
of applying moist air or steam to the materials 
to be sterilized. The requisite temperature is 
obtained by the direct application of heat to the 
sterilizer, which contains a quantity of water 



AGENTS USED FOR PROCURING ASEPSIS. 65 

sufficient to give oft' the required steam. The 
devices invented to carry out these requirements 
are numerous, but they all depend on the same 
principle, the application of a moist temperature 
of high degree. 

The main essentials in any sterilizer are a 
cylinder capable of withstanding a pressure of 
at least twenty pounds ; a door that can be fast- 
ened in such a manner that there can be no 
escape of steam ; a chamber in the cylinder 
large enough to contain the required amount 
of materials; a pan or special section in the 
bottom of the chamber for the reception of 
water which is to be converted into steam ; a 
row of gas-jets or coils of steam -pipes to supply 
the required amount of heat to the outside of 
the cylinder ; steam safety-valve ; pressure-gauge 
and thermometer. All apparatus have these 
essentials; many have improvements added to 
them which make the sterilizer more easily 
managed and at the same time, it is claimed, 
afford better results. Figs. 2 and 3 give an idea 
of the latest sterilizer, which is thought to fulfil 
every possible requirement. 

Those who make use of sterilizers should have 
5- 



Fig. 2. 




66 



Fig. 3. 




o 



t^ 



67 



68 AIDS TO ASEPTIC TECHNIQUE. 

a thorough understanding of the main points in 
regard to the apparatus, in order that the best 
results may be obtained. They should also be 
familiar with the various steps required in ster- 
ilizing by this method. 

When the materials to be sterilized have been 
made into the various bundles and are ready for 
the sterilizer, the space or vessel at the bottom 
of the chamber should be partially filled with 
distilled water. This water is placed in the 
chamber for the purpose of furnishing a suffi- 
cient amount of steam to thoroughly permeate 
every portion of the materials. The latter are 
then placed in the chamber and the door securely 
fastened. The door must be tight-fitting in 
order to prevent the escape of steam and thus 
lower the pressure within the chamber. After 
the door has been fastened, the heat is applied 
beneath the cylinder. In some apparatus there 
is a special appliance by which the air in the 
chamber is removed and a vacuum left. The 
object of removing the air is to allow a greater 
amount of steam in the chamber, and also to 
withdraw as much of the air from the materials 
as possible. If no such appliance be attached to 



AGENTS USED FOR PROCURING ASEPSIS. 69 

the apparatus, the expanded air is allowed to 
escape through the safety-valve as soon as the 
temperature has reached 228° F., with five 
pounds pressure noted on the pressure-gauge. 
When the valve has been opened, the expanded 
air will rush out with considerable force. To 
the hand this air will feel cold, owing to the 
velocity with which it comes in contact with the 
skin. If this expanded air be allowed to remain 
in the chamber it will condense the air in the 
materials, and thus prevent the permeation of 
steam, which is essential in order to obtain ster- 
ilization. After the expanded air has escaped 
the valve is closed. The pressure and tempera- 
ture will again gradually increase, until a tem- 
perature of 250° F., with fifteen pounds pressure, 
is obtained. This temperature and pressure 
should be continued for about fifteen minutes 
in order to allow thorough permeation of every 
portion of the material by the steam. The 
supply of heat is then turned off and the valve 
again opened. This will allow the steam to 
escape from the chamber, the freedom from 
steam at the time the door is opened preventing 
scalding of the hands. Some apparatus have an 



70 AIDS TO ASEPTIC TECHNIQUE. 

attachment by which the steam is withdrawn 
from the chamber, with a resulting vacuum. It 
is claimed that this appliance will allow the dress- 
ing and materials to be perfectly dry when re- 
moved from the chamber, a point that is not 
obtained by the ordinary sterilizer. After the 
steam has all escaped, the door may be opened 
with no fear of scalding. The materials are then 
ready for use as soon as they become cool enough 
to handle. 

For sterilizing instruments, any vessel large 
enough to hold the instruments and enough 
bicarbonate of soda solution to cover them will 
answer all requirements. The apparatus placed 
on the market consist of a large heavy tank, 
fitted with a heavy cover, cocks for withdrawing 
the solution, rows of gas-jets, etc. (Fig. 4.) 
The advantage derived from the heavy cover is 
that the air and generated steam within the 
tank will be under slight pressure, a higher 
degree of heat being insured. The only abso- 
lute essential in any form of sterilizer for instru- 
ments is that it must be large enough to hold 
enough of the solution used to cover all instru- 
ments that may be placed in it. If every portion 



AGENTS USED FOR PROCURING ASEPSIS. 71 

of the instruments be not covered by the solution, 
the parts will be subjected to the action of 
steam, which will cause rusting. A perforated 
tin tray, or one made of wire, is used to receive 
the instruments, the whole being placed in the 

Fig. 4. 




tank after the one per cent, solution of bicarbo- 
nate of soda has been heated to the boiling- 
point. 

The boxes or cans in which the gauze, cotton, 



72 



AIDS TO ASEPTIC TECHNIQUE. 



etc., are sterilized consist of two sections, so 
constructed that one telescopes into the other 
firmly and with but little space between the 
parts. At the base of each section is a row of 
holes encircling the same, about one inch from 
the bottom. When the sections are partly tele- 

Fig. 5. 




scoped these holes will be open, and thus a free 
circulation of steam or hot air is permitted. 
When the parts are completely telescoped, the 
holes are closed; thus the entrance of air is 
prevented and the sterility of the enclosed 
materials is assured. Care must be taken in 
handling the sections, as the slightest dent in 



AGENTS USED FOR PROCURING ASEPSIS. 73 

either will prevent easy adjustment of the parts, 
and, in some cases, will make it impossible to 
telescope them. (Fig. 6.) 

The application of heat by boiling is easily 
accomplished. In some cases nothing but pure 
water is used ; or some material may be added 
to the water to make it antiseptic. Thus, one 
per cent, of bicarbonate of soda is generally 
added for sterilizing instruments; two and a 
half per cent, of carbolic acid for silk and silk- 
worm gut; alcohol, at times, for catgut. Other 
adjuvants may be added at any time when it is 
seen that better results may be obtained. 



Fig. 6. 




74 



CHAPTER V. 

METHODS FOR PROCURING ASEPSIS. 

The ease with which aseptic materials may be 
obtained for use at an operation has very much 
increased of late years. This is due to the great 
advancement in our knowledge of the subject 
of asepsis and to the many improvements that 
have been made in the appliances invented for 
this purpose. 

Sterilization by steam or by boiling should be 
practised whenever practicable, on account of 
the perfect results which are quickly obtained by 
this method. When the use of steam or boil- 
ing solutions is inadmissible, mechanical and 
chemical means must be employed for the pur- 
pose. Whichever is used, the greatest care 
must be exercised in the thoroughness with 
which the procedure is carried out. Especially 
is this true in the asepticizing of the hands of 
the operator and those of the assistants, and of 
the field of operation. It matters not how care- 

75 



76 AIDS TO ASEPTIC TECHNIQUE. 

fully the materials, such as gauze, catgut, and 
instruments, have been prepared, if the field of 
operation be not clean, or if the hands of the 
operator and those of his assistants be not per- 
fectly free from septic matter, the wound is 
bound to become infected. Unfortunately, there 
are but few beginners who realize the importance 
of minor details, passing them by in their desire 
to reach the more prominent, but by no means 
more important, points in their regime. It 
would be perfectly useless for any one to " clean 
up" thoroughly, if he should then stick his 
hands into his pockets, smooth his hair, lean 
on a septic table ; such actions would cause re- 
infection of the parts and render the cleansing 
process valueless. And yet one may frequently 
see the beginner reinfecting his hands in this 
manner and then proceeding with the operation 
without any further preparation. It is well to 
remember that " a chain is no stronger than its 
weakest link," and that forgetfulness or neglect 
of the little points in the regime will render the 
whole procedure practically useless. That sur- 
geon only who looks after every detail, the 
minor as well as the major, who compels his 



METHODS FOR PROCURING ASEPSIS. 77 

assistants both by his example and his warning 
to do the same, is bound to be rewarded by 
aseptic results. 

In all procedures pertaining to a surgical 
operation the greatest care should be exercised. 
One may think the task onerous on account of 
the amount of care and time spent at the work, 
possibly concluding that "the flame is not worth 
the candle." But when one sees the perfect 
results, with the sweet, clean wounds, and has 
the satisfaction of knowing that his care and 
thoroughness have had much to do with these 
results, and in many cases with the mitigation 
of human suffering, if not the saving of a 
human life, he will gladly return to his work 
and find it a pleasure rather than an irksome 
task. 

PREPARATION OF THE PATIENT. 
It is essential that great care be taken in the 
preparation of a patient for an operation. It 
has been fully demonstrated (page 41) that many 
forms of micro-organisms are normally found 
on the surface of the skin and in the skin. 
Hence no field of operation can be considered 



78 AIDS TO ASEPTIC TECHNIQUE. 

free from germs unless the most strenuous efforts 
have been made to remove them. It would be 
useless to expect aseptic results unless the field 
has been carefully prepared. Pus has often 
resulted from neglect of this part of aseptic 
technique, the operator or his assistant thinking 
it sufficient to have sterile materials and instru- 
ments. 

Many methods have been devised by surgeons 
endeavoring to show the best course to pursue 
in order to obtain the best results. These must, 
necessarily, vary but little in their general plan, 
the efficacy of each procedure depending, to a 
great extent, upon the thoroughness with which 
the mechanical points are carried out, the differ- 
ent antiseptics used aiding, also, but to a lesser 
degree. 

The following methods have been thoroughly 
tested with most excellent results : 

The patient is first given a bath with warm 
water and plenty of soap, which remove most 
of the mechanical dirt from the person and 
many of the micro-organisms that are constantly 
found on the surface of the body. This is fol- 
lowed by a rinsing with boracic acid solution, 



METHODS FOR PROCURING ASEPSIS. 79 

for the purpose of removing some of the water 
and soap, and also to further cleanse the body. 
If the patient be a woman, and if the operation 
have anything to do with the genitalia, a vaginal 
douche of bichloride of mercury (1 to 6000) is 
given. The vagina is a favorite site for many 
varieties of micro-organisms, and as many of 
them should be removed or destroyed as pos- 
sible. These germs may be absolutely harmless 
as long as the mucous membrane remains intact, 
but they are liable to become pathogenic if they 
come in contact with the fluids of a wound. 
After the bath, a clean gown is put on the 
patient. The field of operation is then shaved 
and thoroughly scrubbed with soap and hot 
water. The shaving removes all hairs from the 
surface and much of the loose epidermis. This 
is an important procedure, as the hairs are 
always a suitable feeding-ground for many forms 
of bacteria, especially in moist portions of the 
body, as in the axilla. The scrubbing is done 
for the purpose of removing mechanical dirt and 
loose epidermis and many micro-organisms. If 
done thoroughly, the scrubbing will be of more 
avail in making the skin aseptic than any other 



80 AIDS TO ASEPTIC TECHNIQUE. 

step of the entire procedure. A good stiff brush 
should be used, and it should be aseptic or anti- , 
septic. It is essential that it be sterilized before 
using, as the bristles are very apt to contain 
many germs that may find their way to the sur- 
face of the skin, unless they have been destroyed 
beforehand. With a stiff bristle one can ob- 
tain more pressure, and thus scrub the part more 
effectively. It must be borne in mind that the 
efficacy of the scrubbing depends much more 
upon the thoroughness with which it is done 
than upon the length of time devoted to it. 

The part is then rinsed with hot water to re- 
move as much of the soap as possible, and then 
with ether and alcohol to make the field abso- 
lutely free from soap and fatty particles, and 
also from any loose epidermis that may remain. 
Both ether and alcohol act as germicides to a 
slight extent. 

Finally, the field is washed with a 1 to 4000 
bichloride of mercury solution. This is used 
simply as an antiseptic for the purpose of de- 
stroying as many of the germs as can be reached 
by the solution. After the cleansing has been 
accomplished, it is necessary to keep the part 



METHODS FOR PROCURING ASEPSIS. 81 

sterile, and also to destroy any germs that may 
have developed from spores in the skin, or those 
that have worked their way to the surface from 
the deeper layers. For this purpose a towel 
wet with bichloride of mercury solution, 1 to 
4000, is placed over the entire field. This is 
held in place by an aseptic bandage and allowed 
to remain in situ until the patient has been placed 
on the operating-table and the operator is ready 
to proceed. 

Another method varies only in the antiseptic 
solution used. After the scrubbing with soap 
and hot water, the field is thoroughly rubbed 
with turpentine. Turpentine acts as a very mild 
antiseptic, and tends to remove fatty matter and 
loose epidermis that may remain. It is followed 
by the use of soap and hot water in order to 
accomplish its removal. The field is then washed 
with a solution (ten per cent.) of permanganate 
of potash. This acts as a slight germicide, and 
discolors the skin, thus showing that every por- 
tion has been affected by the chemical. Its 
germicidal power is greatly enhanced by the use 
of a two per cent, solution of oxalic acid, which 
should always follow the permanganate. The 

6 



82 AIDS TO ASEPTIC TECHNIQUE. 

acid also removes the stain of the potash solu- 
tion. This is followed by a thorough rubbing 
with alcohol, and this, in turn, by the bichloride 
of mercury solution. The wet antiseptic towels 
are then laid over the field and held in place by 
an aseptic bandage. 

Some surgeons claim that this procedure will 
give better results, that is, a cleaner field, than 
the first. The efficacy of both methods depends 
largely upon the thoroughness with which the 
scrubbing is done. The first is simpler, is much 
easier of execution, does not require as much 
time, and is equally efficient. 

After the patient has been placed upon the 
table, he is covered with warm aseptic blankets, 
the field of operation alone being left uncovered. 
The blankets are then covered with aseptic tow- 
els to prevent the operator or his assistants 
from coming in contact with septic materials 
during the operation, and also to afford an asep- 
tic place upon which instruments and materials 
may be placed in easy reach of the operator. 
The field of operation is then exposed by remov- 
ing the bandage and bichloride towels placed 
over it at the time of the first cleansing. The 



METHODS FOR PROCURING ASEPSIS. 83 

field is rubbed with aseptic gauze wet with ether, 
then with alcohol, and finally with a 1 to 4000 
solution of bichloride of mercury. This proced- 
ure is necessary in order to remove any debris 
and germs that may have accumulated from the 
loose epidermis and from the deeper layers of 
the skin during the time the towels were in 
place. The action of the bichloride is such that 
there is bound to be a minute superficial ne- 
crosis of the epidermis, and this must be re- 
moved by the use of the solutions named. Some 
surgeons advise a second scrubbing with soap 
and hot water, claiming that mere rubbing of 
the surface with the solution will not suffice. 
It is true that the scrubbing is really the most 
essential part of the first preparation, but if 
properly done then, there is no need of a second 
use of brush. The field would very probably 
be again infected from the brush, from the soap, 
or from the hot water, and much of the benefit 
derived from the use of the wet towels would be 
lost. A thorough rubbing with ether, alcohol, 
and bichloride is, however, necessary; it will 
answer all requirements and need occasion no 
fear that the field may become infected during 



84 AIDS TO ASEPTIC TECHNIQUE. 

this cleansing process. After the final cleansing 
the field should be covered, with the exception 
of that portion which the surgeon requires for 
operating space. 

The method for cleansing the hands advised 
by Furbinger and Freyham would be applicable 
to the field of operation, and might possibly 
give better results than either of the procedures 
above described. They claim (page 87) that 
the most efficacious way in which to render the 
skin sterile is by the use of alcohol, in conjunc- 
tion with vigorous scrubbing. Their method is 
to scrub the part thoroughly w 7 ith soap and hot 
water. Then rinse with sterile water to remove 
the soap. Scrub the part with alcohol, and again 
rinse with sterile water. Another antiseptic 
may be used, or the part may be considered 
sterile as it is. The main point to be remem- 
bered in this method is that the sterility of the 
part is accomplished principally by vigorous, 
thorough scrubbing. 

In covering a patient for an operation on the 
abdomen, it will be found of great advantage to 
place a single sheet over the entire body. An 
oval opening large enough to afford plenty of 



METHODS FOR PROCURING ASEPSIS. 85 

room for operative purposes is cut into the sheet 
at the proper place. In this way the part is 
more thoroughly protected, it will be unnecessary 
to sterilize as many towels, and there will be less 
likelihood of the towels that may be used fall- 
ing from the sides of the patient. 

THE HANDS OF THE OPERATOR AND OF HIS ASSIST- 
ANTS. 

Rings or jewelry of any description should be 
removed from the hands and arms before clean- 
ing up for an operation. This is necessary be- 
cause the rings and other jewelry will hide many 
germs that cannot be displaced while the jewelry 
is on the hand. These germs may be washed 
into the wound by some of the solutions used, 
and thus cause infection. Another reason why 
jewelry should not be worn by those coming in 
contact with the field of operation is, that the 
solutions, especially the bichloride of mercury, 
will injure them. 

The nails of all who come in contact with the 
field of operation, or with any of the materials 
used during the operation, should always be kept 
short. The finger-nails are a frequent site for 



86 AIDS TO ASEPTIC TECHNIQUE. 

micro-organisms, and it is almost impossible to 
remove them unless the nails are short. If 
necessary, they should be trimmed immediately 
before cleaning up for an operation, and then 
thoroughly cleaned with a dull-edged instrument 
to remove as much of the mechanical dirt as 
possible. It is a mistake to use a sharp-edged 
instrument, such as the blade of a knife, for this 
purpose, because the sharp edge is liable to de- 
stroy the fine cuticle lining the inner surface of 
the nail, and thus afford a much better lodging- 
place for micro-organisms. A smooth surface is 
least suitable for germs, and for this reason the 
nails should be kept as smooth as possible. 

The surgeon and first assistant should then 
cover their heads with aseptic gauze, bringing it 
well down over the forehead and tying it in the 
back. This gauze is used to prevent any germs 
falling from the hair into the wound, and also 
to collect any perspiration that may form on the 
forehead. The heads of the surgeon and first 
assistant frequently come in contact while work- 
ing over a wound, and unless some preventive 
measures be taken, debris and germs will be dis- 
placed from the hair and gradually settle into the 



METHODS FOR PROCURING ASEPSIS. 87 

wound. Aseptic gauze is better to use for this 
purpose than a skull-cap, for the reason that it 
can be readily fastened in such a manner that it 
cannot be knocked off, and, again, because it is 
sterile. 

The surgeon and his assistants then put on 
their operating clothes, and the surgical cleans- 
ing begins. All of the various methods advo- 
cated to render the hands sterile depend, princi- 
pally, upon the thorough use of a brush and 
soap and hot water. Fiirbringer and Freyham 
have made numerous investigations with regard 
to the hands, and they say that it is practically 
impossible to render them sterile by any method. 
They claim, however, that sterility is more nearly 
reached the more alcohol is used in the process, 
other things being equal. Their method is to 
scrub the hands and arms with hot water and 
soap for five minutes. Then rinse with sterile 
water. Follow this with a scrubbing with alco- 
hol for five minutes, and again rinse with sterile 
water. This may be followed by an antiseptic, 
or the hands may be considered sterile as they 
are. The alcohol is said to act with a three-fold 
effect, — viz. : it is a bactericide ; by dissolving 



88 AIDS TO ASEPTIC TECHNIQUE. 

fats and mixing with the water it prepares a 
way not only for its own germicidal action, but 
also for any subsequent antiseptic that may be 
used; it loosens the epidermis, and dirt, and 
bacteria, and washes them away. The simplicity 
of this method strongly recommends it; it 
would soon supersede all other methods should 
it be proved that the results obtained by it are 
as good as those of the other methods. 

Another method which is strongly advocated 
is carried out as follows. The hands and arms 
are scrubbed with a stiff antiseptic brush, soap, 
and hot water. An aseptic or antiseptic brush 
is used because bristles form a very suitable soil 
for germs, and many of the latter may be depos- 
ited on the skin unless care be taken to destroy 
them before the brush is used. A stiff brush 
is necessary to afford the requisite amount of 
pressure. Recollect that it is not the amount 
of time devoted to the scrubbing that insures the 
best results, but the thoroughness with which it 
is done. Some advise a ten minutes' use of the 
brush. It matters not how long the scrubbing 
may continue, if it be not thorough it will not 
give the desired effect. 



METHODS FOR PROCURING ASEPSIS. 89 

The object of this part of the procedure is to 
remove mechanical dirt, loose epidermis, fatty 
material, and many of the micro-organisms al- 
ways present on the surface of the skin and in 
the pores. The micro-organisms which cause 
the most trouble, on account of their position, 
are those within the pores of the skin. A vig- 
orous scrubbing will often disturb them, and 
either bring them directly to the surface or so 
open the pores that a certain amount of the anti- 
septics may reach them. 

After the first scrubbing, the hands and arms 
are again scrubbed with a clean brush and plain 
hot water. This is to remove the soap and fatty 
materials which may have remained. Some sur- 
geons advise a rinsing with turpentine as the 
next step in the procedure. Turpentine will 
remove any fatty material which may be present, 
but it must be followed by a further use of the 
brush and soap and hot water to accomplish its 
removal. 

During the scrubbing special attention must 
be paid to the finger-nails, to remove as much 
of the remaining dirt and micro-organisms as 
possible. Always remember that the finger- 



90 AIDS TO ASEPTIC TECHNIQUE. 

nails form a very suitable lodging-place for 
germs, and that the greatest care must be taken 
to render them sterile. 

After the scrubbing, the hands and arms are 
immersed in a ten per cent, solution of perman- 
ganate of potash. (Fig. 7.) The permanganate 
acts as a slight germicide, but its value in this 
respect is almost nil unless it be followed by a 
solution of sulphurous acid or oxalic acid. The 
permanganate discolors the skin a dark brown, 
the color remaining until the acid solution has 
been freely used. One decided advantage of this 
action is that the discoloration of the skin shows 
plainly that the solution has come in contact 
with every portion of the exposed hands and 
arms. This will prevent neglect of large sections 
of the skin, as so often happens when an ordi- 
nary non-coloring solution is used. After the 
use of the permanganate, the hands and arms 
are immersed in a two per cent, solution of 
oxalic acid, which is used to enhance the value 
of the potash solution, and also to remove the 
stains of the latter. The oxalic acid must be 
applied freely and until every particle of the 
stain has been removed. This will insure the 



Fig. 7. 




91 



92 AIDS TO ASEPTIC TECHNIQUE. 

complete action of the two solutions, which is 
that of a strong antiseptic. After the acid has 
completely removed the stain of the permanga- 
nate, the hands are washed in a 1 to 1000 solu- 
tion of bichloride of mercury. Bichloride acts 
as a strong antiseptic, inhibiting or destroying 
many of the germs with which it comes in con- 
tact. A too free use of the sublimate, however, 
acts as a hinderance, in that it causes a minute 
superficial necrosis of the epidermis. Hence it 
must be followed by the free use of some other 
solution, preferably alcohol. The alcohol loosens 
and removes some of the necrosed epidermis, 
and dissolves any fatty material that may chance 
to remain. It also attacks any germs that may 
be present, and enters the pores of the skin to a 
slight extent. The arms and hands are then 
thoroughly rinsed in sterilized salt solution, 
which removes the epidermis loosened by the 
alcohol, and also all remaining traces of the 
bichloride solution. The salt solution must be 
aseptic to prevent reinfection of the skin. 

The hands and arms are now " surgically 
clean," and every effort must be taken to keep 
them in that condition. To accomplish this 



METHODS FOR PROCURING ASEPSIS. 93 

great care must be exercised not to touch any 
septic material, table, or instrument. Those 
who are " clean" must not put their hands again 
into their pockets, nor stroke their mustaches, 
nor handle septic basins, nor touch septic tables, 
nor do anything, in short, which would render 
the hands again septic. The hands and arms 
should come in contact with nothing but aseptic 
articles, but if they do, the parts that have thus 
become septic must be again cleansed. 

During the operation the operator and his 
assistants should make frequent use of the salt 
solution that is always at hand, for the purpose 
of removing blood or any other material which 
may have come from the wound, and also to 
keep the parts wet with an aseptic solution. 
When the discharges from the wound are septic, 
the hands should be rinsed in the bichloride 
solution and then in the salt solution. 

It is essential that the hands and arms be 
again asepticized before another operation. No 
one can tell what infection may have been caused 
by the fluids of the preceding case, and in order 
to insure perfect results in the succeeding, the 
hands and arms should be again cleaned. 



94 AIDS TO ASEPTIC TECHNIQUE. 

When wounds, either traumatic or operative, 
are to be dressed, the hands and arms should be 
asepticized in the same manner as when pre- 
paring for an operation. Wounds may be per- 
fectly sweet and clean at the time of the first 
dressing, but may become infected during the 
dressing unless great care be exercised. Many 
beginners are not so careful with the wounds 
which they dress as they should be. The result 
is that many cases that would otherwise continue 
sweet and clean become infected through the 
carelessness of the dresser. The consequent in- 
flammation and suppuration retard convalescence 
and add greatly to the discomfort of the patient, 
and also discourage the beginner in his sup- 
posedly correct notions of asepsis. 

DRESSINGS. 
In preparing the dressing for a wound several 
requirements should be considered. In the first 
place, the dressing must be antiseptic or aseptic, 
as the case demands. A good antiseptic dressing 
will absorb all discharges from the wound ; de- 
stroy all germs that may come in contact with it ; 
prevent access of germs to the wound from the 



METHODS FOR PROCURING ASEPSIS. 95 

exterior; and will not irritate the wound. The 
requirements of an aseptic dressing are the same 
as those of an antiseptic one, with the difference 
that the former has no pow r er to destroy germs. 
These requirements should be studied by the 
assistant, in order that the dressing which he 
provides for the operator may possess all of 
them. 

To remove the discharges from the wound 
the dressing must possess the quality of absorp- 
tion. This quality is readily obtained by using 
soft, pliable gauze for that part of the dressing 
which is applied next to the wound. Such gauze 
will take up and hold the discharges in its meshes 
until removed. 

To destroy the germs that may come in con- 
tact with it that part of the dressing next to the 
wound must contain some antiseptic. Various 
forms of antiseptic gauze have been advocated, 
but those most often used are prepared with 
iodoform or with bichloride of mercury. (Page 
102.) 

To assure non-irritation, the first layer, or that 
portion which comes in contact with the wound, 
must be free from gritty material, and must not 



96 AIDS TO ASEPTIC TECHNIQUE. 

contain too much of an irritating solution. To 
prevent irritation from the dressing some sur- 
geons place a strip of Lister's protective over 
the wound before applying the dressing. It is 
true that the protective so placed prevents irri- 
tation from the dressing, but it removes one of 
the main requirements of the latter, — viz., its 
ability to carry away or absorb discharges from 
the wound. With the protective in place, it is 
next to impossible to so place the gauze that all 
of the discharges will be absorbed. Hence they 
will collect under the protective, and after a short 
time cause much irritation of the wound. In 
this manner the protective not only fails to ac- 
complish the purpose for which it is used, but 
also hastens further infection of the wound. 
The skin is always full of micro-organisms, and 
the collected discharges under the protective 
affords a most suitable nidus where they may 
live, thrive, and multiply. The wound soon be- 
comes infected, and fault is found with the dress- 
ing proper, the instruments, or the preparation 
of the patient, the real cause of the trouble being 
overlooked. Lister used the protective, it is 
true, but simply to protect the wound from the 



METHODS FOR PROCURING ASEPSIS. 97 

strong solutions of carbolic acid used in the 
spray and dressings at that time. 

Silver foil has lately replaced Lister's protec- 
tive. It has the power of destroying the germs 
that may come in contact with it through its 
antiseptic action. It thus protects the wound 
from irritation of the dressing, and destroys the 
germs that may come in contact with it, but it 
also prevents the absorption of the discharges by 
the gauze. 

To prevent irritation of the wound at the time 
the dressing is removed the latter should be 
thoroughly soaked with an aseptic solution. 
This will loosen any adhesions that may have 
formed between the gauze and the edge of the 
wound or the stitches. The dressing may then 
be removed without irritation. 

To prevent access of germs from the exterior 
one or two layers of soft absorbent cotton are 
laid over the gauze. This acts as a sieve, through 
which the germs cannot pass, and also as a 
springy protective by means of which the wound 
is guarded against undue pressure. 

A very essential point in regard to a dressing 
is the manner in which it is fastened in position. 

7 



98 AIDS TO ASEPTIC TECHNIQUE. 

Ordinarily, a bandage properly applied will suf- 
fice, but in abdominal cases, when the patient is 
restless, the dressing is apt to slip from its place, 
and thus expose the wound to the bedclothes or 
to the hands of the patient. In these cases it is 
advisable to fasten the dressing over the wound 
with strips of adhesive plaster. These may not 
be aseptic, but they do not come near the wound 
and are not a source of danger if applied over 
the layers of cotton. Although the patient may 
become restless, the dressing, if secured in this 
manner, will remain over the wound and pro- 
tect it. 

GAUZE. 

In selecting gauze for dressings care should 
be taken to secure such as will fulfil all of the 
requirements. The gauze supplies two of the 
requisites of all dressings^— viz., non-irritability 
and the power to absorb discharges. In anti- 
septic dressings the gauze acts, also, as a vehicle 
for the antiseptic used to destroy the germs that 
may come in contact with it. 

To be non-irritating the gauze must be soft 
and pliable. These qualifications are usually 
possessed by the gauze found in the market. It 



METHODS FOR PROCURING ASEPSIS. 99 

must be free from gritty and irritating me- 
chanical materials ; both on account of their lia- 
bility to irritate the wound and because they may 
readily carry septic matter. To remove the 
discharges of the wound the gauze must be ab- 
sorptive. Most gauze possesses this quality, also, 
especially when properly applied to the wound. 
It is a mistake to place the gauze on a wound in 
a solid layer. The first portion should be un- 
folded and laid on loosely, as it thus forms a 
softer dressing and much more readily absorbs 
the discharges. 

Almost any soft, pliable gauze will suffice to 
carry the antiseptic agents used. Some surgeons 
claim that a large mesh is necessary for a perfect 
iodoform gauze, as the large mesh will take up 
more of the iodoform ; but with a large mesh 
the pliability and softness are apt to be lost, and 
the absorptive power is not so marked as in the 
finer mesh. 

The gauze for dressings is bought in large 
rolls. It is then cut up into lengths of five yards 
each, the full width of the roll. This length is 
readily handled and is economical, in that if a 
new piece be exposed during the operation the 



100 AIDS TO ASEPTIC TECHNIQUE. 

unused portion may be thrown away without 
much loss. These portions are folded and rolled 
into bundles about six inches wide, this being 
the most convenient size for handling. 

The rolls are placed in the can (Fig. 5) pro- 
vided for them and put into the sterilizer. Heat 
is applied to the latter until a temperature of 
about 228° F. and a pressure of five pounds are 
obtained. After the expanded air has escaped 
through the valve (page 69), the valve is closed 
and the heat continued until a temperature of 
250° F., with fifteen pounds' pressure, is obtained. 
(Page 69.) The gauze is allowed to remain in 
this temperature and under this pressure for 
fifteen minutes. This length of time allows the 
steam, which is under pressure, to permeate 
every fibre of material in the can, and the high 
degree of moist heat assures absolute destruction 
of all germs that may be present. After fifteen 
minutes' exposure the supply of heat is turned 
off, and the valve is opened to allow the escape 
of steam. This should be done before the door 
is opened, to prevent accidental scalding from 
the hot air which would otherwise rush from the 
latter exit. After the steam has escaped the 



METHODS FOR PROCURING ASEPSIS. 101 

door may be opened. As soon as the cans can 
be handled without danger of burning, they 
should be firmly closed by aseptic hands. The 
gauze is then ready for use as plain aseptic 
gauze. It should be kept in the cans until 
needed for use. Formerly, the gauze was taken 
from the can at once and placed in sterile glass 
jars or wrapped in wax paper. These pro- 
cedures are not only unnecessary but are also 
detrimental to asepsis, as the gauze is very 
liable to become infected during the handling, 
from the glass jar or from the wax paper. All 
gauze that is to be used as plain aseptic gauze 
should be allowed to remain in the can until 
needed. 

The plain gauze thus prepared is used for 
most of the dressing in aseptic surgery. When 
it is needed, the one having charge of the dress- 
ings should open the can with aseptic hands, and 
then unroll as much as may be needed with asep- 
tic forceps, cutting off the length required with 
aseptic scissors. As soon as the required amount 
has been removed the can should be covered 
with an aseptic towel, to prevent infection from 
the air. 



102 AIDS TO ASEPTIC TECHNIQUE. 

This plain gauze is nearly always used instead 
of sponges during the operation. Sponges were 
found to be unsatisfactory on account of the 
difficulty in making them perfectly aseptic ; they 
are much more expensive than gauze, and they 
are not more efficient. For these reasons they 
have been discarded almost entirely, and plain 
gauze has been substituted, either in flat pieces 
or in balls. The pieces should be cut from the 
aseptic roll just before the operation and care- 
fully counted. (Page 153.) They should then be 
covered with an aseptic towel, to prevent infection 
from the air. 

When an antiseptic bichloride gauze is desired, 
the sterile rolls are placed in a 1 to 1000 bichlo- 
ride of mercury solution and allowed to remain 
there until thoroughly saturated, when they 
should be removed with aseptic hands, wrung 
dry, and placed in sterile jars with tight-fitting 
covers. (Page 132.) Or they may be unrolled and 
soaked in the solution, wrung out with aseptic 
hands, and re-rolled. 

Ordinary iodoform gauze is prepared by soak- 
ing the aseptic gauze in a mixture consisting of 
iodoform, 5 parts ; glycerin, 20 parts ; and al- 



METHODS FOR PROCURING ASEPSIS. 103 

cohol, 70 parts, by weight. This mixture will 
furnish the so-called five per cent, iodoform 
gauze ; a ten per cent, gauze is made by doubling 
the quantity of iodoform in the mixture. The 
gauze should be thoroughly kneaded while in 
the mixture to insure perfect permeation of the 
iodoform. When thoroughly saturated, as can 
be readily seen by the uniform yellow color, the 
gauze is removed from the mixture and wrung 
out with aseptic hands until it is as dry as pos- 
sible. It is then folded and rolled and placed in 
aseptic jars with tight-fitting aseptic covers. 

It is necessary to wring the gauze dry after im- 
mersion in the iodoform mixture, in order to re- 
move the supersaturation of alcohol. Alcohol is 
a marked irritant to wounds, and will often cause 
the patient intense suffering. It is used in the 
preparation of iodoform gauze simply as the 
vehicle for the iodoform. The glycerin aids the 
alcohol, and prevents the gauze from becoming 
too dry after it has been made. If the gauze 
become too dry, the iodoform will be shaken 
from it during handling. 

Many objections have been made to iodoform 
gauze prepared as above described : it has been 



104 AIDS TO ASEPTIC TECHNIQUE. 

claimed that the gauze is not antiseptic, that it 
is very irritating, and that the glycerin acts as 
a hinderance by causing a serous exudate from 
granulating surfaces. To overcome these objec- 
tions Pryor, of New York, has suggested a 
method of preparation which he claims affords 
an antiseptic, non-irritating gauze that will re- 
main sterile even when soaked with the dis- 
charges of a wound. He places the sterile gauze 
in a twenty per cent, ethereal solution of iodo- 
form for ten minutes. It is then wrung out and 
allowed to stand in a basin covered by an aseptic 
towel for about twelve hours, for the purpose of 
allowing the ether to completely evaporate. At 
this stage the gauze is a greenish-blue in color, 
and will respond to the test for free iodine. It 
is then soaked in a 1 to 4000 aqueous solution of 
bichloride of mercury, which restores the origi- 
nal color of the iodoform and insures the anti- 
septic quality. After an immersion of about 
twelve hours in the bichloride solution, it is wrung 
out as dry as possible, folded and rolled. It is 
then ready for use, and should be kept in sterile 
glass jars until needed. It is claimed that gauze 
prepared in this manner is non-poisonous, as the 



METHODS FOR PROCURING ASEPSIS. 105 

iodoform will not be absorbed ; that contact with 
the discharges of a wound will liberate the iodine 
and thus prevent a septic condition of the gauze, 
even w r hen soaked ; that it does not have to be 
changed as often as the ordinary gauze ; that it 
is non-irritating and antiseptic. 

COTTON. 

The cotton used for dressings must be soft and 
readily absorbent. Its absorbent power can be 
easily determined by using a small piece of it as 
a siphon. If one end of the piece be placed in 
a bowl of water while the other end hang out- 
side of the bowl, the water will be carried over 
the edge of the vessel by the cotton. The 
rapidity with which the siphon acts varies with 
the absorbent quality of the cotton. In a good 
material each fibre should absorb the water and 
carry it over the edge of the vessel readily and 
quickly. 

The cotton should also be of fine texture and 
absolutely free from gritty material. It should 
be carded in such a manner that the different 
layers can be readily separated. 

It is bought in large rolls. These are un- 



106 AIDS TO ASEPTIC TECHNIQUE. 

wrapped, and the paper between the different 
layers is taken out. The cotton is then cut up 
into the desired lengths, about twelve inches, and 
either laid flat in the telescoping conveyance 
box or folded and then placed in the tin. It 
should be sterilized in the same way as the gauze, 
described on page 100. 

After sterilization, it is kept in the tin until 
needed for use, when the cover of the can is 
removed, and the can covered with an aseptic 
towel to prevent infection from the air. All 
cotton that remains after an operation should be 
resterilized before it is used. 

TOWELS. 
The towels used during an operation should be 
smooth, soft, firm, and free from fringe or fancy 
work. Small towels are preferable to large ones, 
as they are more readily handled and are more 
convenient in every way. They should be 
thoroughly washed and ironed before they are 
used at all, for new towels are, as a rule, stiff, 
and almost always contain mechanical matter 
that can be removed only by a thorough washing 
with soap and hot water. After they have been 



METHODS FOR PROCURING ASEPSIS. 107 

cleansed, they should be folded and wrapped in 
a sheet. The latter is to be pinned in place, and 
the bundle then treated in the sterilizer. (Pages 
69, 100.) 

After the towels have been sterilized, the 
sheet is left intact until they are needed, when 
the pins are removed and as many of the towels 
as may be wanted are taken from the bundle. 
The sheet should be again closed over the re- 
maining towels, in order to protect them from 
the germs of the air. 

SUITS FOR OPERATOR AND ASSISTANTS. 

Many forms of suits have been devised for the 
use of the surgeon and his assistants. Probably 
the most satisfactory one for the operator and 
his male assistants consists of a pair of trousers 
and a short-sleeved coat ; for the nurses, a large 
gown. The main essentials in any form are, that 
the suit should cover all of the other garments 
worn, and should be able to withstand steriliza- 
tion. White duck or heavy bleached muslin is 
the best material from which suits can be made. 

A suit consisting of trousers and coat is much 
more convenient for the operator than is the full 



108 AIDS TO ASEPTIC TECHNIQUE. 

gown, as it gives greater freedom of motion and 
is less trouble to put on. It entirely covers the 
back, the back of the thighs, and the back of the 
legs, whereas the gown leaves these parts ex- 
posed. 

The suits worn by any one coming in contact 
with the field of operation or with any of the 
materials used at an operation should be steril- 
ized. Unless this be done there would be great 
liability that the surgeon or one of his assistants 
might convey unknown quantities of germ life 
to the patient, and thus make sepsis almost a 
certainty. 

The suits should be folded and wrapped in a 
large sheet, placed in the sterilizer in the wire 
cage (Fig. 5), and subjected to a temperature 
of 250° F. for fifteen minutes under fifteen 
pounds pressure. The same method of steriliza- 
tion must be followed as in the sterilization of the 
gauze, cotton, etc. "When the suits are needed, 
the sheet may be opened and the suit removed 
from the bundle. It is well to remember that 
the suit should come in contact with non-steril- 
ized materials as little as possible. 



METHODS FOR PROCURING ASEPSIS. 109 

INSTRUMENTS. 

Before an operation one very important duty for 
the assistant is to select the proper instruments. 
Nothing is more exasperating to a surgeon than 
to find that he needs a certain instrument during 
an operation which has not been sterilized and 
laid out with the others. In such cases he must 
either do his best without the forgotten instru- 
ment or wait untill it has been put through the 
sterilizing process. The latter procedure would 
delay the operation in its course and keep the 
patient under the anesthetic a longer time 
than is desirable. It would also afford a better 
opportunity for infection of the wound. To 
avoid these complications the assistant should 
be thoroughly acquainted with the instruments 
used during the various operations, and should 
know the special ones needed for any particular 
case. The assistant should also be well ac- 
quainted with the whims and special preferences 
of his chief. 

In selecting instruments only those should be 
chosen which are absolutely perfect. Many a 
surgeon has been provoked, to say the least, by 



110 AIDS TO ASEPTIC TECHNIQUE. 

picking up a hseniostat at a critical point in the 
operation and finding it too loose for the pur- 
pose intended, or with catches that will not hold. 
Every heemostat should be examined before it is 
put into the instrument-case, and if it be not per- 
fect it should be discarded until repaired. 

Knives and scalpels form another cause of 
annoyance. An operator requires a cutting 
instrument that will cut, not only when he first 
incises the skin but also afterward. Hacking 
operations have often been performed simply 
because the operator was not furnished with a 
sharp knife. To avoid this, the one having 
charge of the instruments should see that every 
knife has a good cutting edge before it is placed 
in the case. 

To sharpen a knife correctly is a fine art pos- 
sessed by few. The edge must be fine, but not 
so fine that it will turn and nick readily. A 
wire edge must be avoided. The character of 
the edge that can be obtained and maintained 
on a blade depends largely upon the quality and 
the temper of the steel. A fine quality of steel, 
properly tempered, must first be obtained, and 
then so sharpened that the edge will be fine 



METHODS FOR PROCURING ASEPSIS. Ill 

and lasting. Most knives require whetting every 
time they are used. 

Saws must have good cutting teeth. If the 
points of the teeth become dull, or broken, or 
bent, the cutting edge that remains will prevent 
one from obtaining neat results with that instru- 
ment. The teeth must be straightened and sharp- 
ened before it is placed in the instrument-case. 

Scissors cause much trouble for the surgeon. 
A frequent fault is the failure of the cutting 
edges to come into the proper relation with each 
other when closed. A loose joint will render a 
pair of scissors useless, no matter how sharp the 
cutting edges may be. If the edges do not come 
together as they should, the tissues will slip 
between the blades and remain intact. The 
cutting edges should be sharp, but the proper 
relation of the two blades when closed is even 
more important. 

All the joints of the modern " aseptic" instru- 
ments should be frequently examined, for, unless 
exceptionally well made, they soon wear and 
become loose, or the fastenings may become 
loose and turn on themselves, thus destroying 
the proper relation of the parts. 



112 AIDS TO ASEPTIC TECHNIQUE. 

The easiest and quickest method for sterilizing 
instruments is by boiling. Before it became 
known that chemicals are not essential to asepsis, 
instruments were almost always rendered sterile 
by the use of those agents. The instruments 
were allowed to stand in a solution of carbolic 
acid for fifteen or twenty minutes before using 
them, which was decidedly unsatisfactory, as it 
was shown that carbolic acid does not always 
render instruments sterile. Another objection 
was found in the length of time required for 
the process. Carbolic acid is also objectionable 
because it is very irritating to most hands and 
very liable to cause a superficial necrosis of the 
epidermis. At the present time chemicals are 
seldom used in preparing the instruments or in 
keeping them sterile after they have been ren- 
dered aseptic. 

To procure aseptic instruments they should be 
boiled in a one per cent, solution of bicarbonate 
of soda for about ten minutes. The solution is 
prepared and put into the apparatus (Fig. 4) pro- 
vided for the purpose and heated to the boiling 
point. The instruments are then placed in the 
solution and boiled for ten minutes. 



METHODS FOR PROCURING ASEPSIS. 113 

For ease of handling and to assure cleanliness 
the instruments are generally placed on a wire 
tray. This is put entire into the solution by 
means of two handles or hooks. The latter are 
used to prevent scalding of the hands and to 
prevent septic hands from coming in contact 
with the tray. In removing the tray with the 
instruments the same handles are used. 

This method of sterilizing the instruments 
affords a temperature of 212° F., and the benefit 
also of an antiseptic. The soda prevents rusting 
and removes all fatty or greasy material that may 
be present on the instruments. 

Why the soda prevents rusting is not ex- 
plained, but that it does so no one can deny. 
When instruments are boiled in plain distilled 
water, the water works its way into the small 
cracks in the nickeling and rusts the exposed 
metal of which the instrument is made. In 
this way large flakes of the nickel coating become 
detached, and soon the instrument is rendered 
useless. With the soda solution, on the other 
hand, there is no tendency to undermine the 
nickeling, and there is no rusting in those cases 
where the nickel has been cracked. None of 

8 



114 AIDS TO ASEPTIC TECHNIQUE. 

the soda solution remains on the instruments 
after use, however, on account of the frequent 
rinsing in salt or other solutions, which removes 
every particle of it. Hence the instruments are 
liable to rust unless they are thoroughly cleaned 
and dried before they are replaced in the instru- 
ment-case. 

It is well to remember that all instruments 
with a sharp cutting edge, such as scalpels, will 
lose their fine edge if boiled in any solution for 
ten minutes, as the heat may disturb the temper 
of the knives, and thus make them practically 
useless as cutting instruments. They should be 
boiled for only two minutes, being placed in the 
solution after the other instruments have been 
boiled for about eight minutes. 

After the boiling process the tray should be 
lifted from the bath and placed on an aseptic 
towel, another aseptic towel being used to cover 
the tray and instruments. When chemicals were 
used to prevent the instruments from again be- 
coming septic the tray, after the boiling, was 
placed in a porcelain vessel deep enough to hold 
sufficient quantity of a two per cent, solution of 
carbolic acid to entirely cover the w r ire tray and 



METHODS FOR PROCURING ASEPSIS. 115 

all of the instruments. With the aseptic pro- 
cedures this is unnecessary, as the instruments 
can be kept sterile by wrapping them in aseptic 
towels. 

All instruments that are boiled in the soda 
solution must be entirely covered by the solu- 
tion. This is necessary to prevent any part of 
the instrument being exposed to the action of 
the steam which is generated. If such should 
occur, there would be rusting of the exposed 
portion. The steam is aseptic and hot enough 
to destroy any germ that may be reached by it, 
but it will rust the instruments, and for this rea- 
son the latter must be entirely covered by the 
solution. 

All instruments having aluminum handles 
must be sterilized by boiling in a two per cent, 
solution of carbolic acid. The soda solution not 
only discolors this metal, making it almost black, 
but it also causes discoloration of all other instru- 
ments that may be in the solution with the 
aluminum. This action is not noticed when 
carbolic acid is used. 

Remember that any instrument is to be 
banished from the operation should it fall on the 



116 AIDS TO ASEPTIC TECHNIQUE. 

floor or come in contact with any septic material. 
In order to be again suitable for use it must be 
put through an asepticizing process. If the 
operator be in a hurry, and also in great need of 
the instrument that has become septic, a simple 
method of sterilizing it is to pour alcohol over 
it and then ignite the alcohol. This will effect- 
ually destroy any germs that may have become 
attached to the instrument. It should be rinsed 
in the salt solution to remove the remaining 
alcohol, when it may again be used. 

After an operation all instruments should be 
scrubbed with a brush, soap, and hot water. 
This is done to remove grease or fatty material, 
blood, or other debris that may have soiled them. 
Sand soap has been frequently used for this 
purpose, but it is highly objectionable because it 
will eat into the nickeling of the instrument, and 
thus increase the liability to rust. Another thing 
to remember is that the gritty particles of the 
soap will destroy the fine edge of the cutting 
instruments. If there be any difficulty in remov- 
ing the blood from the instruments, they should 
be boiled in the soda solution. After the scrub- 
bing they are to be rinsed in hot water to remove 



METHODS FOR PROCURING ASEPSIS. 117 



Fig. 8. 




118 AIDS TO ASEPTIC TECHNIQUE. 

the soap, dried thoroughly, and put into their 
proper places in a dust-proof case. The cleanest 
case, surgically, that can be obtained is made 
entirely of glass and iron. (Fig. 8.) 

NEEDLES, 
Needles should be asepticized by boiling for 
two minutes in a one per cent, solution of bicar- 
bonate of soda. It is important that the point 
be kept as sharp as possible, hence a long-con- 
tinued boiling is bad; nor is it necessary, as 
needles are so perfectly smooth that it is difficult 
for micro-organisms to cling to them. The eye 
of the needle, however, is a suitable lodging for 
them, and care must be taken to see that the eyes 
are sterile. To prevent dulling of the points or 
of the cutting edges, the needles should be stuck 
into a piece of aseptic gauze and thus boiled. 
After the sterilizing process the piece of gauze 
with the needles in it should be wrapped in 
another piece of aseptic gauze, or laid between 
the folds of an aseptic towel. This is done to 
prevent infection from the air. The needles 
should be removed from the gauze only when 
needed. It is often convenient to thread some 



METHODS FOR PROCURING ASEPSIS. 119 

of them with the required sutures and then re- 
place them in the gauze or between the folds of 
an aseptic towel. They are then ready to be 
used, and there will be no delay when the opera- 
tor demands them. 

Before re-threading a needle during an opera- 
tion it should be carefully rinsed in the salt 
solution to remove any debris or germs that may 
have become attached to the eye. It will be 
remembered that the skin is always full of germs, 
and that it is almost impossible to destroy all of 
them by our asepticizing processes. When a 
suture passes through the skin it may carry 
many of these germs with it, and the latter will 
then be scraped from the suture by the eye of 
the needle when it is withdrawn. To prevent 
the germs being again carried into the skin by 
the needle or suture, the needle should be care- 
fully rinsed in the salt solution before it is re- 
threaded. 

To avoid this infection from the skin while 
suturing many surgeons have abandoned skin 
sutures entirely, using instead the subdermal or 
buried suture. In this way the infection from 
the skin is avoided, as no needle or suture passes 



120 AIDS TO ASEPTIC TECHNIQUE. 

through it, and hence the germs are not dis- 
turbed. 

SPONGES. 

Sponges are seldom used in surgery to-day, 
gauze, either in balls of strips, replacing them. 
The reason that sponges have received such a 
decided set back in surgical work is because of 
the great difficulty experienced in making them 
absolutely sterile. The task is not only arduous 
but also very unsatisfactory. The main advan- 
tage found in the sponge is that it readily ab- 
sorbs blood and discharges, but the trouble in 
cleaning them and the uncertainty of their 
sterility more than counterbalance their useful- 
ness ; they have, consequently, been left almost 
entirely out of the operator's list of necessary 
articles. 

If sponges be required they should be pre- 
pared as follows. In the first place, good sponges 
should be obtained. They should be or firm 
texture, not easily torn, and free from hard por- 
tions. They should be thoroughly beaten to 
break up and remove much of the calcareous 
material always found in sponges. They are 
then thoroughly washed with soap and hot water 



METHODS FOR PROCURING ASEPSIS. 121 

to remove all mechanical dirt. It is important 
during the cleaning to feel for gritty particles, 
and to remove them either with the fingers or 
by cutting away the small portion of the sponge 
in which they are found. After a thorough 
washing with soap and hot water they are again 
washed in plain hot water, and then placed in a 
weak solution of hydrochloric acid to remove 
any remaining calcareous particles. After stand- 
ing in this solution for twenty-four hours the 
sponges are again washed in hot water to remove 
the acid and any gritty particles that may be 
found. They are then thoroughly washed in a 
five per cent, solution of carbolic acid, which is 
well worked through the entire sponge, replacing 
the water that remains from the previous wash- 
ing. After a thorough cleansing they are im- 
mersed in a fresh five per cent, solution of car- 
bolic acid and allowed to stand for twenty-four 
hours. The carbolic acid bath is repeated until 
the solution remains perfectly clear and clean, 
when the sponges are placed in a sterilized glass 
jar containing a five per cent, carbolic acid solu- 
tion, and allowed to remain in it until needed for 
use. It is necessary for the jar to have a tight- 



122 AIDS TO ASEPTIC TECHNIQUE. 

fitting glass cover, otherwise the solution will 
evaporate quickly. 

After a sponge has been used it should be 
thrown away. The only exception to this rule 
might be made in those cases where the entire 
procedure is absolutely aseptic. But even here 
the sponge must be thoroughly rewashed several 
times in carbolic acid solution. The safest way 
is to discard every sponge that has once been 
used. It is impossible to clean sponges that have 
been filled with pus or mucus. 

Sponges should not be sterilized by heat, 
because they w T ould then soon become so rotten 
that they would fall apart. The danger of using 
a rotten sponge, especially in abdominal cases, is 
that a portion of it may break off and remain in 
the peritoneal cavity after the wound has been 
closed. The use of gauze in place of sponges is 
a decided advantage, not only in the absolute 
sterility, but also in the ease with which the 
sterility may be obtained. 

CATGUT. 
The great advantages accruing from the use 
of a perfect catgut are so many that most sur- 



METHODS FOR PROCURING ASEPSIS. 123 

geons prefer it for certain purposes to all other 
forms of ligature or suture. Its greatest advan- 
tage is that it is absorbed by the fluids of the 
body, so that no part of it is left as a foreign 
body to cause irritation. But to secure a catgut 
that will answer all of the purposes required of 
it is one of the hardest tasks allotted to the pre- 
parer of materials for use during an operation. 
It is easy to secure a perfectly aseptic gut, but in 
the process of preparation its strength may be so 
impaired as to render it useless, or it may become 
very brittle, or so soft that it will be too quickly 
absorbed. So difficult is it to secure a perfectly 
aseptic gut possessing strength and toughness 
and lack of brittleness that many surgeons of 
eminence have discontinued its use, preferring 
silk for all sutures and ligatures. 

The methods advanced for asepticizing catgut 
are numerous, and every one has some point of 
advantage. Each surgeon has his own idea as 
to the proper way to prepare the gut ; some find 
fault with the results and then abandon catgut 
entirely, others have perfect results and continue 
with a method that failed in the hands of some 
other operator. 



124 AIDS TO ASEPTIC TECHNIQUE. 

In the first place, a good catgut must be ob- 
tained. Many of the guts sold are so poor that 
they become rotten in a short time, no matter 
what procedure be followed in their preparation. 
Others are rotten before they are touched. A 
good, tough, clean gut must be procured, and 
the greatest care exercised in its preparation. 
Of the many methods advanced for the prepara- 
tion of catgut the following has given excellent 
results at the Philadelphia German Hospital. A 
good catgut is placed in a perfectly sterile glass 
vessel in the ordinary coils in which it is pur- 
chased, covered with absolute ether, and allowed 
to soak for twenty-four hours to dissolve out all 
the fatty matter. The ether is then poured off*, 
and the gut is covered with a solution consisting 
of bichloride of mercury, 20 parts; distilled 
water, 400 parts ; and alcohol, 2000 parts. This 
solution acts as a germicide and also removes 
any remaining ether or fatty matter. It is re- 
newed three times, at intervals of twenty-four 
hours. This renewing of the solution is neces- 
sary in order to destroy all germs that may be 
present and any spores that may develop. The 
solution is finally poured off, and the gut is 



METHODS FOR PROCURING ASEPSIS. 125 

allowed to soak in absolute alcohol for twenty- 
four hours, when it is placed in fresh alcohol 
until needed for use. This method may possibly 
fail occasionally, and to be sure of a sterile gut 
the bacteriological tests should be made with 
every preparation. If several portions of the 
prepared gut prove to be sterile it may be used. 
If any portion prove to be septic, that is, if it 
contain germs, the whole amount of gut should 
be put through the same process again. It is 
seldom that this has to be done, as the method 
generally affords absolute sterility and a gut 
that will answer the other requirements. 

Vollmer has modified a method proposed by 
Kossman for sterilizing catgut by immersion in 
formalin. Vollmer cuts the raw catgut into the 
lengths required, and wraps each piece separately 
in filter-paper that has been soaked in a two per 
cent, solution of formalin for twenty-four hours. 
The gut is allowed to remain in this paper for 
about twenty-four hours, and it is then dried at 
a temperature of 140° F. It is kept in the dry 
condition until needed for use, when it should be 
soaked for a few minutes in a sterile fluid. 

Saul boils the gut in a solution consisting of 



126 AIDS TO ASEPTIC TECHNIQUE. 

ethyl-alcohol, 85 parts; liquefied phenol, 5 parts; 
and distilled water, 10 parts. The gut is boiled 
in an apparatus which is so constructed that it 
will keep the solution at a given temperature, 
without high pressure, for fifteen minutes; Saul 
claims that this method will thoroughly asep- 
ticize the gnt and will not interfere with its 
strength and toughness. 

Kronig has advocated the boiling of catgut in 
cumol, which has a boiling point of about 170° C, 
a temperature high enough to destroy any germs 
that may be present. His method is as follows : 
" 1. Roll the catgut into rings. 2. Dry in a hot- 
air oven or over a sand-bath for two hours at 
70° C. 3. Heat the cumol to a temperature of 
165° C, a little short of the boiling point, for 
one hour. 4. Transfer to petroleum benzine for 
permanent preservation." It is claimed for this 
method that it absolutely sterilizes the gut, ren- 
ders it strong and smooth but not slippery, and 
reliable in every way. 

Numerous other methods have been advanced, 
but the above will give an opportunity to ex- 
periment with the gut. If none of them afford 
a thoroughly satisfactory material after repeated 



METHODS FOR PROCURING ASEPSIS. 127 

tests, they should be discarded and some other 
method investigated or devised. The procedure 
first described will give results as good as any 
if proper care be exercised. 

SILK. 

Silk may be prepared for an operation with 
little trouble. A good material should be ob- 
tained, and then boiled a length of time varying 
with the weight of the silk. 

Heavy silk, such as that used for tying off 
pedicles (No. 4), should be boiled for twenty to 
thirty minutes in a two and a half per cent, solu- 
tion of carbolic acid. The temperature attained 
together with the antiseptic solution will render 
the silk absolutely sterile. It can then be kept 
aseptic by placing it in alcohol until needed for 
use. It is understood that the vessel into which 
the silk is placed after the boiling must be abso- 
lutely sterile. (Page 131.) 

Medium weight silk (No. 3) should be boiled 
for fifteen or twenty minutes. Pine silk (No. 5 
card), such as is used for suturing wounds in the 
intestine, should be boiled for five minutes. The 
difference in time allowed for the boiling of the 



128 AIDS TO ASEPTIC TECHNIQUE. 

different weights of silk is necessary, as the re- 
quirements for one weight would be insufficient 
for another, or else so excessive that it would rot 
the material and thus render it useless. 

The silk should be boiled immediately before 
the operation, for this is the surest way of se- 
curing a perfectly sterile article. Silk that has 
once been boiled should be kept in alcohol. If 
it has not been handled or exposed to the air it 
may be used at a subsequent operation. Ke- 
member that silk will rot if boiled too frequently. 

SILKWORM-GUT. 

Silkworm-gut is the material most often used 
for suturing wounds after an operation. It is 
easy to handle, is readily sterilized, and easily 
kept aseptic. On account of the ease of supply- 
ing a perfectly sterile article silkworm-gut has 
almost entirely supplanted catgut as a suture, 
and to a great extent silk also. 

The worm-gut is purchased in bundles with 
rough, stringy ends, which should be cut off and 
discarded. It is boiled for fifteen minutes in dis- 
tilled water, and then placed in alcohol until 
needed for use. Many surgeons prefer to use an 



METHODS FOR PROCURING ASEPSIS. 129 

antiseptic in the preparation of the worm-gut, 
which not only stains the gut but also renders it 
antiseptic, the latter quality, it is claimed, de- 
stroying any germs with which it may come in 
contact while acting as a suture. The coloring 
also renders the sutures more prominent, and 
hence more readily found when ready for re- 
moval. The easiest method for accomplishing 
these ends, and one that will answer every pur- 
pose, is as follows : the worm-gut is first freed 
from its rough, stringy ends, and then placed in 
a one per cent, solution of methyl violet, where 
it is allowed to remain for twenty-four hours. 
This solution stains the gut a dark blue, and also 
renders it antiseptic. After the exposure to the 
methyl violet, the gut is boiled for fifteen min- 
utes in distilled water. Some of the antiseptic 
will be removed by this boiling, but enough will 
remain to leave a permanent stain. The gut is 
then placed in alcohol, and kept there until 
needed for use. 

Some surgeons claim that this antiseptic 
quality of the gut will destroy the germs in the 
immediate vicinity of the tract of the suture, on 
account of absorption of the methyl violet by 

9 



130 AIDS TO ASEPTIC TECHNIQUE. 

the fluids of the body. As the stain of the gut 
remains constant, even after long exposure to 
the fluids of the body, it is probable that this 
claim is exaggerated, as the methyl violet re- 
mains intact. 

KANGAROO TENDON. 

In most instances this material is purchased 
already sterilized and ready for use. When the 
raw tendon is bought, the process of preparing 
it is very similar to that used in asepticizing cat- 
gut. The tendon is placed in sterile glass vessels 
and covered with absolute ether, where it is 
allowed to remain for thirty-six hours. The 
ether dissolves all the fatty material that may be 
present. It is then poured off, and the tendon is 
covered with the following solution : bichloride 
of mercury, 20 parts ; distilled water, 400 parts ; 
and alcohol, 2000 parts. This solution is re- 
newed four times, at intervals of twenty-four 
hours. It removes the remaining ether and 
fatty material and acts as an antiseptic, de- 
stroying all germs that may be present. It is 
necessary to renew the solution four times on 
account of the thickness of many of the strands 
of the tendon ; the frequent renewal assures the 



METHODS FOR PROCURING ASEPSIS. 131 

complete destruction of the germs that may be 
hidden deep in the strand and of the spores. 
After the fourth renewal of the bichloride solu- 
tion the latter is poured off and the tendon 
covered with absolute alcohol. This is used to 
remove any water that may be present, and also 
to strengthen the tendon. After an immersion 
in the latter for twenty-four hours the absolute 
alcohol is poured off and fresh alcohol added, 
in which the tendon is allowed to remain until 
needed for use. 

Bacteriological tests should be made of sev- 
eral of the strands before the tendon is used. 
If no growth be obtained it may well be con- 
sidered sterile. If growth occur, all of the 
tendon should be again put through the same 
process of sterilization. 

GLASS VESSELS. 
All the vessels used for the reception of cat- 
gut, silk, silkworm-gut, etc., should be made of 
glass, because this is the material that is most 
easily sterilized and kept aseptic. One great 
advantage of glass is that it may be boiled in 
almost any antiseptic solution without injury. 



132 AIDS TO ASEPTIC TECHNIQUE. 

Another advantage is that all mechanical dirt 
attached to it can be very easily seen. 

Each vessel should be thoroughly cleaned 
with soap and hot water, special, attention being 
paid to the angles and corners. After this 
cleansing, which removes most of the mechan- 
ical dirt, they should be boiled for fifteen minutes 
in a solution of bichloride of mercury 1 to 1000; 
if they be too large to be boiled in a solution, the 
boiling solution should be poured into them and 
allowed to stand for four or five hours. The 
high temperature together with the antiseptic 
solution will render inert all germs that may be 
present. 

After the use of the bichloride solution the 
vessels should be well rinsed with aseptic distilled 
water for the purpose of removing any of the 
bichloride solution that may remain. They are 
then ready for use, and should at once be cov- 
ered with a tight-fitting aseptic cover prepared 
in the same manner, or with an aseptic towel, to 
prevent the access of germs from the air. 

The covers of glass jars should be tight-fitting, 
and should slip over the edge of the jars rather 
than inside of them. They should be tight-fit- 



METHODS FOR PROCURING ASEPSIS. 133 

ting in order to prevent the access of air, which 
is always full of germs, and also to prevent any 
draughts of air from forcing germs that may by 

Fig. 9. 



chance lie between the lid and the jar into the 
latter. They should be outside the jar, so that 
no germs will be forced into the jar when the 
cover is put in place. (Fig. 9.) 

BASINS. 
The enamelled basins, or agate-ware basins 
(Fig. 10), required for the various solutions used 
during the operation, and those used by the sur- 



134 AIDS TO ASEPTIC TECHNIQUE. 

geons in washing their hands, should be thor- 
oughly cleaned with soap and hot water to 

Fig. 10. 




remove all mechanical dirt and greasy matter. 
They are then allowed to stand in a 1 to 500 
solution of bichloride of mercury until needed 
for use, or filled with this solution. When 
needed, they should be rinsed with sterile water 
to remove all traces of the bichloride solution. 

SALT SOLUTION. 
The salt solution so much used in aseptic 
surgery of to-day is probably the best solution 
obtainable for irrigating and cleansing. It is 
non-irritating, non-poisonous, easily sterilized, 
and readily kept in an aseptic condition. It is 
generally made in the strength of six-tenths of 
one per cent. This proportion is obtained by 
adding six grammes of ordinary salt to each one 



METHODS FOR PROCURING ASEPSIS. 135 



Fig. 11. 



thousand cubic centimetres of sterile water used. 
As much of the solution should be made as may 
be needed at one time, although it is always 
better to have too much on hand than too little. 
If properly sterilized, and if the proper precau- 
tions be followed, a quantity of sterile solution 
may be kept constantly on hand. 

Special flasks (Fig. 11) have been devised for the 
purpose of sterilizing the solution, and they have 
been found most satisfactory. After the flasks 
have been thoroughly cleaned 
with boiling water or chemicals, 
they are rinsed well with plain 
aseptic water to remove any debris 
or chemicals that may remain. 
The solution is then put into the 
flask, space being left at the top 
to allow for boiling. In filling the 
flask, it is advisable to run the 
solution through an aseptic filter 
for the purpose of removing any mechanical 
dirt or debris that may be in the salt. A plug 
of aseptic cotton is then placed in the mouth of 
the flask and the latter is put into the sterilizer. 
Heat is applied and the solution in the flasks 




136 AIDS TO ASEPTIC TECHNIQUE. 

allowed to boil for ten minutes. The heat of the 
sterilizer will cause expansion of the air within 
the flask and drive much of it through the stop- 
per. When the solution and air cool, fresh air 
will be drawn into the flask. This is no objec- 
tion, as the cotton has the power of filtering all 
germs and debris from the air. To overcome 
any objection that might be made to this filtered 
air a special rubber top has been devised to take 
the place oi the cotton. A minute hole in the 
centre of this top allows the escape of the ex- 
panding air, and the contraction during cooling 
draws the top so firmly to the neck of the flask 
that the entrance of air is absolutely prevented. 
A partial vacuum is left in the space above the 
solution, which keeps the contrivance firmly in 
place. If this top be used instead of the cotton, 
it should be removed just before the operation 
and substituted by a wad of aseptic cotton. 
This cotton plug should be removed from the, 
flask only when the solution is needed. 

DRAINAGE-TUBES, CATHETERS, ETC. 
Drainage-tubes, catheters, bougies, syringes, 
etc., should all be sterilized before they are used. 
They often are the cause of infection, and special 



METHODS FOR PROCURING ASEPSIS. 137 

care should be taken to render them aseptic. 
With all glass and metal instruments this can be 
done very easily by boiling them in a one per 
cent, solution of bicarbonate of soda, or a two 
per cent, solution of carbolic acid, for ten minutes. 
They are then placed in a solution of carbolic 
acid and kept there until needed. Before they 
are used they should be rinsed in an aseptic 
solution, preferably of salt, for the purpose of 
removing all of the antiseptic used, which is es- 
pecially irritating to the mucous membrane of the 
urethra and is liable to cause a mild urethritis. 

Rubber catheters, drainage-tubes, etc., may be 
sterilized in the same manner. It is difficult to 
render these instruments absolutely aseptic with- 
out injuring them, as the rubber will become 
rotten if boiled often. Rubbing w T ith a piece of 
gauze wet with an antiseptic solution, and then 
with a piece of aseptic gauze, will rid the ex- 
terior of all germs, but the inside will still be 
septic. This may be rendered practically free 
from germs by a thorough irrigation with a 
strong antiseptic solution, to be followed by salt 
solution or distilled water. 

Hypodermic syringes may be sterilized by 



138 AIDS TO ASEPTIC TECHNIQUE. 

boiling in most cases, or by allowing them to 
soak for some length of time in a two per cent, 
solution of carbolic acid. Syringes that are 
made entirely of glass or metal, with no leather 
or rubber washers, are readily sterilized by boil- 
ing for ten minutes. When the washers are 
present, they will swell at first and then so con- 
tract that they will be useless. Such syringes 
can be fairly well sterilized by drawing alcohol 
through them several times. When the instru- 
ments consist of two different materials, such as 
glass and metal, the former is liable to break 
during the boiling on account of the unequal 
expansion under heat. Such syringes should be 
rendered clean by drawing alcohol through them 
four or five times. 

On account of the difficulty experienced in 
sterilizing syringes with washers, or those made 
of two different materials, it is advisable to use 
those that are constructed entirely of metal. 
These may be rendered absolutely sterile by 
boiling for ten minutes in bicarbonate of soda 
solution or carbolic acid solution. They should 
always be rinsed with distilled water or salt solu- 
tion before they are used. 



CHAPTER VI. 

THE OPERATING-ROOM. 

There have been such great advances in 
regard to the appliances requisite for the aseptic 
and antiseptic procedures of the modern oper- 
ating-room that the technique is much more 
easily managed at present than it was some years 
ago. With the present forms of apparatus and 
a certain amount of care no excuse can be given 
for faulty materials or instruments. Most oper- 
ating-rooms are so well equipped with time-saving 
devices readily managed that nothing but care- 
lessness on the part of the operator or his assist- 
ants can account for septic results in the vast 
majority of cases. One should not think, how- 
ever, that the minutest details can be safely 
neglected, for many a case of pus, pyaemia, or 
septicaemia has been due to neglect of these 
small things. Every detail, minor or major, 
must be carefully attended to in order to obtain 
the best results. 

139 



140 AIDS TO ASEPTIC TECHNIQUE. 

Most modern operating-rooms contain but few, 
if any, articles that cannot be asepticized. The 
room should be constructed of those materials 
that can be thoroughly washed or scrubbed with 
strong antiseptic solutions. Marble, tiling, iron, 
and glass are the best materials, as they are most 
readily cleaned. Wood-work is a detriment to 
any room that is intended for surgical work, as 
the joints, cracks, nail-holes, etc., are always a 
suitable lurking-place for germs. With marble, 
tiling, iron, and glass every crack or crevice can 
be permanently sealed, every surface made per- 
fectly smooth, and every part thoroughly cleaned. 
With the advent of formaldehyde, however, 
many of the objections to the wood-work in 
operating-rooms have been overcome. This gas 
is said to have the power of penetrating every 
crack and crevice, and also of destroying every 
germ with which it comes in contact. 

The floor should be of tiling, for it may then 
be frequently washed and scrubbed without 
injury. In the centre should be a drain with a 
trap so constructed that when closed it will abso- 
lutely prevent the entrance of germs or gas from 
the pipes below. This trap should be covered 



THE OPERATING-ROOM. 141 

and tightly closed before and during the opera- 
tion. It is for use only while the room is being 
cleaned, and at all other times it should be shut, 
and covered with a tight-fitting copper plate. 

A large hopper for the reception of waste 
solutions should be near at hand. It should be 
made of painted iron or enamelled porcelain. 
These smooth surfaces may be readily cleaned 
and are not liable to infection. All attachments 
and connections with pipes should be well 
nickeled and perfectly free from cracks and 
crevices. The hopper should be large in order 
that the waste solutions may be thrown in freely. 
The trap must be in perfect condition to prevent 
the access of gas and germs from the drain- 
pipes. 

A wash-stand or sink is necessarily present or 
near at hand. This should be made of porcelain 
or granite-ware with well-constructed joints. 
The trap to the outlet must be perfect to prevent 
the entrance of gas and germs from the pipes. 
A free supply of hot and cold water should be 
connected with the sink, the spigots being 
operated by attachments worked by the feet. 
(Fig. 12.) This arrangement will preclude the 



142 AIDS TO ASEPTIC TECHNIQUE. 

use of the hands in stopping the flow of water 
after the hands have been cleaned. 

Fig. 12. 




A free supply of hot and cold sterile water is 
always needed in an operating-room. If pos- 
sible it should be prepared in the room, and not 
carried from another part of the building. The 
latter procedure will make it most difficult to 
keep the water sterile and free from irritating 



THE OPERATING-ROOM, 143 

materials. It must be reheated if needed hot. 
The supply is liable to run out at a critical part 
of the operation where delay might be detri- 
mental to the patient. 

The water used must be clear, free from irri- 
tating matter, and sterile. Appliances have been 
devised by which the proper quantity and quality 
may be prepared in the operating-room. " It is 
essential that the apparatus for water sterilization 
be so constructed that water once prepared for 
the use designed be held free from liability to 
accidental fertilization, and that it can be drawn 
without contamination from atmospheric causes." 
Fig. 13 represents one of the best forms of appa- 
ratus designed for this purpose. It is fitted with 
a special system of pipe connections and with an 
" atmosphere filtering vacuum" valve, through 
which filtered air is allowed to pass to fill the 
vacuum caused by the withdrawal of water. The 
water is introduced into the tanks through an 
aseptic filter. It is then heated by steam and 
boiled tor fifteen or twenty minutes under ten 
pounds pressure. This length of exposure to a 
high temperature under pressure will accomplish 
the destruction of all germs that may be present 



144 



AIDS TO ASEPTIC TECHNiqUE. 



in the filtered water. A special apparatus pro- 
vides for the cooling of the water in the cold- 



Fig. 13 




water tank. "With this complete appliance a 
bountiful supply of hot and cold sterilized water 
is always at hand. 



THE OPERATING-ROOM. 145 

There should be within easy reach a rack of 

^IG. 14. 




glass jars (Fig. 14) containing various antiseptic 

10 



146 AIDS TO ASEPTIC TECHNIQUE. 

solutions of varying strengths. These solutions 
will seldom be needed in aseptic surgery, but 
they must always be ready, as the operator may 
unexpectedly open a pocket of pus, or he may 
fear that the wound has become septic through 
other causes. In these instances he will call for 
an antiseptic solution. Before the jars are used 
they should be boiled or thoroughly washed with 
soap and hot water to remove all mechanical 
dirt and greasy material, and then allowed to 
stand for ten or twelve hours full of a 1 to 1000 
solution of bichloride of mercury. After the 
bichloride has been poured off the mouth of the 
jar is closed with a wad of aseptic cotton until 
used. 

The tables or stands upon which instruments, 
trays, solutions, and the other requirements are 
placed should be made of iron and glass, per- 
fectly plain. This reduces to a minimum the 
liability of infection from concealed germs and 
allows of thorough cleansing. They should be 
fitted with rubber rollers so that they may be 
easily and noiselessly moved. (Fig. 15.) 

Porcelain or agate-ware trays and basins 
should be used for all solutions, instruments, 



THE OPERATING-ROOM. 147 

etc., as they are the most readily cleaned and 
the least liable to be broken. These trays 

Fig. 15. 



should be thoroughly cleansed with soap and 
hot water to remove all dirt, grease, and many 



148 AIDS TO ASEPTIC TECHNIQUE. 

germs. They are then filled with a 1 to 1000 
solution of bichloride of mercury and allowed 
to stand until needed. Before they are put to 
use they should be thoroughly rinsed with sterile 
water to remove all traces of the bichloride. 

"When it is thought advisable to keep the in- 
struments in an antiseptic solution during the 
operation a deep tray should be used, so that all 
the instruments may be entirely covered by the 
solution. It should be large enough to readily 
hold the wire tray on which the instruments 
have been boiled. It should be made of porce- 
lain or agate-ware and sterilized before being 
used. 

Various designs for operating-tables have been 
suggested. The best one, from an aseptic stand- 
point, is made entirely of iron and glass, with, 
possibly, a thick soft rubber slab, on which the 
patient is to lie. The iron part should be made 
as plain as possible to prevent the presence of 
nooks and crevices in which germs may lodge. 
The top of the table should be made of glass, or 
some other material that may be easily cleaned 
with antiseptic solutions. It should also be 
removable, so that all portions beneath may be 



THE OPERATING-ROOM. 149 

freed from any dirt that may have lodged there 
during the operation. The large rubber pad 
that covers the glass is used to lessen the danger 
of bruising the patient, and also to prevent the 
chilling of the patient by conducting the heat 
from the body. The pad may be cleaned with 
boiling water and soap and then with antiseptic 
solutions. It should be covered with aseptic 
towels or a large aseptic sheet before the patient 
has been placed on the table. 

The air of the operating-room should be kept 
as free from germs as possible, but it is extremely 
difficult to obtain absolute sterility in a hospital, 
as the various wards and halls are certain to con- 
tain germs of an infectious character. Then, 
again, every one entering the room is bound 
to carry germs unless proper precautions have 
been observed. 

As was shown by Tyndall in his numerous 
experiments, the germs in the air will gradually 
settle. To allow this to occur in the operating- 
room, the air should be undisturbed for several 
hours before an operation ; the germs will gravi- 
tate to the floor, and for a time the air above 
will be absolutely free from micro-organisms. 



150 AIDS TO ASEPTIC TECHNIQUE. 

Every one entering the room, however, will stir 
them up and cause them to be circulated freely 
by the currents of air. To prevent this there 
should be no unnecessary moving around in the 
room, and no person should come near the oper- 
ating-table who is not needed there. After the 
operation the room should be sprayed with an 
antiseptic solution, or exposed to the fumes of 
formaldehyde. The former will carry the germs 
to the floor, from which they can be washed by 
the antiseptic used in cleaning the latter. When 
formaldehyde is used the germs in every portion 
of the room will be destroyed, and the air, con- 
sequently, made sterile. The pungent, pene- 
trating odor of the gas can be overcome to a 
great extent by evaporating ammonia water in 
the room, j 

Any person who expects to be near the oper- 
ating-table should remove his ordinary coat and 
replace it by an aseptic one before entering the 
room. This will lessen the liability of germs 
falling from the upper portion of the person to 
the table. It is always preferable to have no 
one in the operating arena who has not thor- 
oughly cleaned up before entering it. 



THE OPERATING-ROOM. 151 

Common courtesy or professional etiquette 
may tempt the operator to invite all visitors to 
view the operation from a position close to the 
table. Aseptic sense and a regard for the con- 
dition of the wound, however, would compel 
him to request his visitors to remain as far from 
the field of operation as possible, or to clean ap 
and put on aseptic clothes before coming near 
the table. Many a case of sepsis has been caused 
by the neglect of this point in aseptic technique. 

AN ASEPTIC OPERATION. 

An aseptic operation, as generally understood, 
is one in which no antiseptics are used during 
the operation to destroy germs or to prevent 
their access to the wound. In other words, 
nothing but aseptic materials, solutions, instru- 
ments, etc., is used; no antiseptics are allowed 
to come in contact with the field of operation or 
with the wound, or with any of the materials or 
instruments. 

The air of the operating-room should be 
allowed to remain as quiet as possible for about 
two hours before the operation. Sterilization of 
the air by formaldehyde, if undertaken, should 



152 AIDS TO ASEPTIC TECHNIQUE. 

begin about six hours before the time of opera- 
tion, in order to afford time for the dissipation 
of the gas and thus prevent an excess at the 
time of the operation. The surgeon and his 
assistants should prepare for the operation before 
entering the operating-room. This is done to 
prevent the entrance of germs on the clothes. 
The assistant having charge of the arrangements 
should clean up before putting the various 
materials in their proper places. The operating- 
table should be prepared for the reception of 
the patient before he is brought into the room. 
The table holding the instruments should be back 
of the operator, so that he may select such as 
he may need, or back of the first assistant, 
who can thus take charge of the instruments 
and relieve the surgeon of that trouble. Near 
the surgeon and assistant should be basins con- 
taining sterilized salt solution, in which they 
may rinse their hands as often as required. 
Sterile water may be used instead of salt solu- 
tion for this purpose. The solution or water 
should be changed as often as it becomes 
contaminated with blood or discharges. The 
table holding the dressings, sutures, and liga- 



THE OPERATING-ROOM. 153 

tures should be placed back of the first assist- 
ant, being in charge of the second assistant or 
nurse. Everything that may be needed should 
be under aseptic towels. There should be a 
special form of arrangement of these materials, 
so that the one in charge knows exactly where 
each article is without hunting for it under the 
towels. Back of the operator should be another 
assistant in charge of the sponges or pieces of 
gauze used for cleansing purposes. Before all 
operations in any of the cavities of the body, 
these pieces of gauze or the sponges should be 
carefully counted and their number jotted down 
so that it will not be forgotten. This is essential 
in many cases, as a safeguard against leaving a 
piece within the cavity. Cases are on record 
where this has occurred with consequent death 
of the patient. Every piece of gauze should be 
accounted for before the cavity is finally closed. 
A fourth assistant should be at hand to change 
the solutions, to supply the ansesthetizer with 
ether, and to be generally useful. This assist- 
ant must be especially careful in regard to the 
hands, as they are liable to come in contact 
with articles that are septic. A free use of the 



154 AIDS TO ASEPTIC TECHNIQUE. 

bichloride followed by salt solution will pre- 
vent infection of the aseptic articles that must 
be handled afterwards. During the operation 
nothing that is not sterile should be handled 
by the operator or his assistants; should they, 
however, touch anything septic, their hands 
must be again cleaned before proceeding with 
the operation. It is essential that each one of 
the assistants have his own special duties, and 
that he attend to them and to nothing else. 
Nothing is more demoralizing to the proper 
morale of an operating-room than interference 
with the duties of another. 



INDEX. 



Agents used for procuring asep- 
sis, 47. 
Air of operating-room, 149. 
Alcohol, 61. 

method of disinfection, 87. 
Aluminum, sterilization of, 115. 
Anecdote of Lister, 11. 
Antiseptic procedure, 18. 

solutions, 145. 
Antiseptics, ancient use of, 10. 

use of, 19. 
Aseptic procedure, 18. 

Bacteria, 27. 
Bacteriology, 22. 

knowledge of, 22. 
Bacterium coli commune, 31. 
Basins, 133. 

Bicarbonate of soda solution, 113. 
Bichloride of mercury, 48. 
Boiling water, 73. 

Carbolic acid, 50. 

spray, 17. 
Care of finger-nails, 85. 
Catgut, 122. 

Kronig's method, 126. 

preparation of, 124. 

Saul's method, 127. 

tests for, 25. 

Vollmer's method, 125. 



Catheters, 137. 
Chemical agents, 48. 
Citrate of silver, 60. 
Conditions affecting germs, 15. 
Corrosive sublimate, 48. 
Cotton, 105. 

as a filter, 13. 

preparation of, 104. 

qualities of, 104. 
Creolin, 62. 

Decinormal salt solution, 20. 
Distilled water, use of, 20. 
Drainage-tubes, glass, 137. 

rubber, 137. 
Dressings, 94. 

among ancients, 9. 

essentials of, 94. 

preparation of, 98. 

Ether, 61. 

Flasks for salt solution, 135. 
Formaldehyde, 51. 
uses of, 56. 

Formalin, 58. 
Gauze, 98. 

bichloride, 102. 

iodoform, 102. 

plain aseptic, 101. 

155 



156 



INDEX. 



Gauze, preparation of, 99. 

qualities of, 98. 
Germs as cause of putrefaction, 

14. 
Germ-tests, 24. 
Glass vessels, 131. 
Glutol, 59. 

Hands, preparation of, 85. 

History, 9. 

Hypodermic syringes, 137. 

Idiosyncrasy of patients, 24. 
Infection, sources of, 34. 

unavoidable, 23. 
Instruments, 109. 

aluminum handles, 115. 

care of, 116. 

rusting of, 113. 

selection of, 109. 

sterilization of, 70, 112. 
Iodoform, 59. 

gauze, 102. 

Kangaroo tendon, 130. 

Lactate of silver, 60. 
Lister, 11. 

theory of, 15. 
Lister's protective, 96. 
Lysol, 63. 

Micro-organisms, 12. 

Nails, care of, 85. 
Needles, 118. 

Operating-room, 139. 
air of, 149. 



Operating-room, care of, 139. 

construction of, 140. 
Operating- table, 148. 
Operation, an aseptic, 151. 
Oxalic acid, 90. 

Pasteur, germ theory of, 14. 
Patient, preparation of the, 77. 
Permanganate of potash, 50, 90. 
Preparation of the hands, 85. 

of the patient, 77. 
Principle of putrefaction, 16. 
Protective, Lister's, 96. 
Pryor's iodoform gauze, 104. 
Putrefaction caused by germs, 
14. 

theories to explain, 13, 14. 

Rusting of instruments, 113. 

Salt solution, preparation of, 
134. 
use of, 20. 
Silk, 127. 

Silkworm-gut, 128. 
Silver-foil, 60, 97. 
Silver wire, 60. 

Sources of infection, field of op- 
eration, 39. 
materials, 43. 
the air, 34. 
Sponges, 120. 

preparation of, 120. 
Spontaneous generation, theory 

of, 12. 
Spray, carbolic acid, 17. 
Staphylococcus epidermidis albus, 
30. 
pyogenes albus, 32. 



INDEX. 



157 



Staphylococcus pyogenes aureus, 

28. 
Sterilization by boiling, 75. 

by steam, 75. 
Sterilizer, 65. 

use of, 68. 
Streptococcus pyogenes, 29. 
Suits for operator, 107. 

preparation of, 108. 
Sutures, subdermal, 119. 
Syringes, hypodermic, 138. 



Testing for germs, manner of, 

25. 
Tests, germs, 24. 

method of making, 26. 

value of, 24. 
Towels, 106. 
Turpentine, 61. 

Wash-stand, 141. 
Water, distilled, use of, 20. 
sterile, 143. 



THE END. 



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